Milliman’s clinical consultants conduct both real-time and
retrospective claims audits to identify areas where cost savings can be
optimized. We also help develop IT-system checks to identify potential
areas of savings.
To help reduce loss ratios, Milliman has
developed ClaimsRef—evidence-based clinical reference criteria for
checking the appropriateness of hospital-billed items. ClaimsRef assists
insurance companies and Third Party Administrators (TPAs) with
identifying any variance from the usual and customary hospital billing
patterns. It can be used for both real time and retrospective audits and
is currently available for 200 inpatient conditions. ClaimsRef is
available as an online tool, which provides access to detailed clinical
Pilot claim audits help insurers identify cost savings
pilot claim audits with multiple TPAs and Insurers, Milliman’s clinical
team trained insurers/TPAs to conduct real-time audits with ClaimsRef.
This tool helped identify potential overpayments and excessive or
unwarranted billed items. Insurers and TPAs found potential cost savings
of 4-8%, of which 2-4% savings were realized. For a portfolio with Rs
100 Crores of claims paid, this amounts to a savings of Rs 2-4 Crores.