Claims Governance. Version 1.0

Transcription

1 Claims Governance Version 1.0

2 P a g e 1 TABLE OF CONTENTS TOPIC PAGE OVERVIEW PRODUCTION FINANCIAL QUALITY & COMPLIANCE 7-8 UNDERWRITING & AGENCY 8-9

3 P a g e 2 OVERVIEW Business intelligence is obtained through use of reporting to conduct ongoing trend analysis and business advisory. Data is extracted and organized from the following sources: AS400/Point company accounting and financial record Advance Claims claims management system (implemented 01 Aug 2011) Claims Dispatch FNOL application and record External other sources of data, either provided by vendor or through web application/site. All three data sources are necessary as each provides detailed reporting on the different aspects of the claims operation. As long as claims are open that were reported prior to the implementation of Advance Claims, the AS400 is still needed to provide data on their status and progress. Advance Claims can only provide data on those claims that were reported since implementation of that system. The following diagram illustrates the relationship between system data sharing: Some notes regarding Advance Claims and AS400: AS400 reports reflect data which is current as of the prior business day. AS400 updates at the end of business at 8pm EST (Monday Friday). Activity in Advance Claims will not be reflected in the AS400 until the following business day. Advance Claims reports are real time reporting. Any activity conducted in Advance Claims can be captured in a report from Advance Claims that same day. Checks entered into Advance Claims are not printed until the next business day at 7am. NOTE unbroken arrows indicate that data is exchanged and shared while broken lines indicate nonsharing of data: PRODUCTION Production includes the following metrics: Number of claims received and number of claims closed as well as number of claims reopened.

4 Status of claims: open, reopened, closed. P a g e 3 Cycle time from when claim was reported and reserve opened, to when claim was concluded and reserve closed. Length of time on when field adjuster received assignment, inspected loss, and returned the estimate to the desk examiner. How many field assignments are pending in the field, how long they have been pending in the field and who have the assignments. FNOL Claims are reported to Cypress either by phone or through the company website. Claims in the form of First Notice of Loss (FNOL) are input into the FNOL application, Claims Dispatch. The screens in the application are completed through pre-populated information from policy or through question prompts regarding the details of the loss. The claim data is then loaded into Advance Claims (AC) which assigns a claim number. By the next business day, the claim data is also populated in the AS400 to reflect the claim number and financial information created in AC. Assignment Claims are assigned through auto-routing based on claim criteria from Claims Dispatch. For those claims which do not fit the routing criteria, those claims are manually assigned by the Customer Care Unit (CCU). The following reports are utilized to measure assignment and production performance: Name Data Source Frequency of Use Details CM Claim Activity AS400 Daily # of claims pending in current month Status of claim (O, C, R) # of claims reported and number of claims closed during current month Ad Hoc Claims Dispatch Weekly Shows number of claims reported by state and cause of loss type as well as CAT or non-cat. Gives loss description (i.e. water appliance, water plumbing, etc.). Provides call center detail as to when FNOL was taken and who was the FNOL agent. Gives count of how many FNOL reports were taken by phone and how many through web portal. Assignment Aging Xactanalysis Weekly Avg days of assignments in the field to include time it takes from assignment to inspect, and inspection to estimate returned. AC Aging Advance Claims Daily Number of claims pending, the examiner to whom the claims are assigned, and number of days claim has been open from notice of loss date.

5 P a g e 4 PA File Advance Claims Monthly PENDING Aged Litigation Advance Claims Monthly Provides age of suit, status of suit as well as venue, plaintiff firm and defense firm. State Litigation Advance Claims Annually Required report submitted to the Dept of Insurance for each state containing the following: Calendar year activity regarding Non-CAT new lawsuits received, lawsuits concluded, and lawsuits pending as of year-end. Calendar year activity regarding CAT new lawsuits received, lawsuits concluded and lawsuits pending as of year-end. Appraisal Advance Claims Monthly Lists cause of loss involved in the appraisal Provides data on the appraisers and the umpire involved in each appraisal. Illustrates variance between appraisal awards and the undisputed amount prior to appraisal. Illustrates the timeline of when appraisal is invoked and when the appraisal is concluded. Subrogation Mitigation Claims by Entity Advance Claims Quarterly Lists those claims that have subrogation activity and provides the status of the recovery. Illustrates variance of amount paid and amount recovered. Illustrates timeline of when subrogation is recovered from when it was referred to the subrogation Claims Dispatch Monthly Lists those FNOLs that qualified and auto-routed an assignment to a provider for mitigation, emergency services or temporary housing needs. Sinkhole Template Manual Weekly FL Sinkhole claims pending by AY, by status in claim (i.e. first testing, second testing, denial) as well as due date to conclude current phase of handling. SPDR s AS400 Monthly Number of claims closed and reported Number of claims reopened during the month and the reopen ratio (# of claim reopened /# of claims closed) Number of claims paid and number of claims CWOP as well as CWOP% (# of claims CWOP / total number of claims closed) Large Loss Advance Claims Daily Claims that are pending with an aggregate incurred of over $25,000 and to which desk examiner is assigned to those claims. Cypress External Weekly Field assignment count to CatManDo which gives status of claim and cycle time of field assignments. Rytech-Cypress External Monthly List of mitigation assignments and assignments for

6 P a g e 5 comparative estimates for the month. CAT AS400 Monthly PENDING CAT Litigation AS400 Monthly PENDING FINANCIAL At time of FNOL, reserves are set at a stat reserve amount. See Reserving Guidelines at the following link: Florida\CPCI Reserving Guidelines.docx Every 90 days a reserve reconciliation is conducted on all open claims greater than 30 days aged. The reconciliation is done with the claims officer, management staff, the adjuster assigned to the file as well as legal counsel if needed. This practice is conducted to ensure appropriate reserving of claims. Results of reserve changes and those claims reviewed in the process are documented and logged at the following link:..\reserve Reconciliation Claims located in AC require that all reserve changes and check issue be conducted through the AC system. Those claims that existed prior to August 2011 that do not exist in the AC system (Legacy claims) require that the checks be issued through the AS400 system directly. Checks on Legacy files Check requests are made or entered by the handling adjuster into the pre-check register and then reviewed and reconciled by claims administration to either reject or pay. Those checks approved are moved to the print file and printed through a check printer at a secure terminal. Claims administration batches the checks with the appropriate claims documents and mails them to the addressee. Those checks that were entered by one of our independent claims adjusting partners, Lozano Insurance Adjusters (LIA), are printed and mailed at their site. Checks on Advance Claim files AC is programmed to allow adjusters and managers only that reserving or check writing authority that was entered into the system with approval from the Chief Claims Officer. When a reserve change or check request is made through AC for an amount greater than their authority, the system escalates a notification to the next higher level for review of the reserve change or payment. All rejection or approval of financial transactions are conducted in AC and recorded in the Financial Detail History tab in the specific claim file. The IBNR is established by the Finance Department based on a review of trends in the claim settlement process. The following reports and analytics are used to review and manage the following metrics:

7 P a g e 6 Name Data Source Frequency of Details Use CM Claim Activity AS400 Daily Track incurred amount MTD and understanding drivers to forecast end of month incurred amount for each state. AC Aging Advance Claims Daily List of claims with open reserves, indemnity and/or loss and amount paid to date. Large Loss Advance Claims Daily List of claims with aggregate reserve + paid of over $25k as well as amount of reserves on FREEZE status that are pending approval. PA File Advance Claims Monthly Illustrates expense and loss dollars paid in claims involving public adjusters. Litigation Advance Claims Monthly Provides information on budgeted defense costs, spend against budget and current reserves. Appraisal Advance Claims Monthly Illustrates appraisal awards against the amount that was undisputed before appraisal was invoked. Subrogation Advance Claims Monthly Illustrates amounts collected against gross loss and expense dollars paid by cause of loss. SPDR s AS400 Monthly Amount of loss dollars paid and reserved by cause of loss. Amount of expense dollars paid and reserved by cause of loss. Average indemnity paid per claim by cause of loss. Reserves by AY. Current Incurred with AY Development AS400 Weekly Shows claims and their incurred amount for the current month, broken out by Accident Year to get incurred by AY MTD. Sinkhole Reserve Tracking All AY Manual Weekly Shows current incurred for each claim pending by Accident Year. Rytech-Cypress External Monthly CAT AS400 / AC Monthly PENDING CAT Litigation AS400 / AC Monthly PENDING List of mitigation assignments for the month with a comparative of flat fee costs against actual mitigation cost to understand benefit or lack of benefit from flat fee pricing. UNDERWRITING & AGENCY The following reports are provided to Cypress underwriting department as well as to various agencies/brokerages:

8 P a g e 7 Name Data Source Frequenc y of Use Details Agency Claim List AS400 Monthly List of claims closed and opened with adjuster name and claim status since inception of business. Currently only the Ted Todd Agy and the Westwood Agy receive these reports. Multi-Claims AS400 Weekly s sent to underwriting of those policies that have more than one claim reported. FL/TX Claim Data AS400 Annually to GenRe for reinsurance information on per risk non-cat exposures and development. Provided thru Herb Curlee. Cypress-GenRe AS400 Quarterly Update report on non-cat per risk exposures with actual or potential exposure over $450k. Provided to Tim Fletcher with GenRe. 90 Day Closed Claim Advance Claims Monthly Provided to underwriting on those paid claims which were closed for 90 days and should have repairs effected in order for us to maintain the risk.