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LTCG Balances Technology and Human Touch in Claims Processing


Long Term Care Group (LTCG) is a leading provider of business process outsourcing services for the insurance industry. They are the largest third party long term care insurance provider offering underwriting, policy administration, clinical services, as well as claims processing and care management for America’s largest insurance companies. Insurers rely on LTCG for these services due to LTCG’s deep expertise in long term care portfolios, which require specialized knowledge and processes. LTCG continually invests in the people, processes, and technology to maintain their leadership position in the industry.

Several years ago LTCG developed and implemented an automated claims adjudication process using Sparkling Logic SMARTS as the decision engine. Prior to this initiative more than 90,000 claims per month were processed manually by LTCG’s team of claims examiners. LTCG wanted to reduce the time their claims examiners needed to spend researching and making a claims decision in order to maintain the highest levels of customer satisfaction.

Long term care insurance is unique in that benefits are coordinated by care coordinators who create a plan of care to help policyholders leverage the benefits covered by their policy based on clinical guidelines that direct care needs over time. Due to the unique nature of long-term care needs, LTCG wanted to balance the use of technology with their emphasis on human touch to ensure the best possible care and coverage for policyholders.

The first automated claims adjudication system was developed in 6 months using an agile methodology and Sparkling Logic SMARTS. The Scrum team was able to iterate on the business rules and logic quickly thanks to the simplicity and power of the SMARTS user interface and software architecture.

Download the LTCG Case Study to learn more.

Is Insurance ready for the disruption swarm?

After years of disruption in the banking and payments industry, tech rebels are setting their sites on an adjacent financial target – insurance. According to SVIA, this is a $5T prize, where several new technology trends are converging to change the face of insurance. Like a swarm of locusts, new business models, shared economy, Internet of Things and core technology advances have all made leaps in the last few years, promising great change on the face of the established insurance institutions.

digital insurance applications
Applications of Digital Technology in Insurance, source: Deloitte
In a recent LinkedIn blog post, I wrote about recent developments in the Silicon Valley, where numerous startups work daily to challenge status quo, long overdue for an overhaul. To compete in the new insurance economy, insurance IT, business analysts and data scientists will ALL need to rethink core tools they use to discover, test AND rapidly deploy their business models. It will be increasingly important not only WHAT decisions are made, but also how QUICKLY. Fast discovery, testing and nimble deployment are essential to compete in the battle that is about to engulf the insurance industry.

Modern SaaS, analytics and decision rules engines like Sparkling Logic allow insurance players to quickly discovery and modify business and risk logic. 20-year-old tools simply will not do. Without latest tools platforms, insurance carriers will find it difficult to defend themselves against modern fraud, advanced risk and emerging insurance business models.

Social Media New Order: Be Nice, Be True

Social & Friendly

Social Media has been soaring in the workplace during the tough years of the recession and keeps getting momentum.  With reduced budget for travel and less personnel, providers and end-users have been creative in finding ways to leverage the social media platforms.  Many ideas have popped up here and there to leverage Twitter or Facebook, some better than others of course.

I found pretty interesting this enthusiasm for true relationship, even if partially digital.

During one of my discussions with Betsy Burton from Gartner, we talked about what may have caused it.

The Chicken and The Egg (again)

I know… I do like this analogy…  For a biologist by trade, it is a fundamental question of course.  But let’s not digress…  Back to Social Media and Relationships…

Gartner explained in an early Pattern-Based Strategy presentation that people turned slowly into numbers.  Think about it: we are our social security number, we are our credit card number…  If this was not the case, identity theft would not thrive as much as it does.  People are getting more aware of that unfortunate reality and as a result value “human relationship” more than they have in the past: it differentiates them from their digital existence.

Social Media was there at the right time.  Extensively used by teenagers, suddenly it became exciting to the workforce as well.  Services like Twitter allowed professionals to interact with thousands or millions of tweeps around the world.  Talking about your everyday life on Twitter may have sounded unproductive initially but it fulfilled the human aspect: being personal, sometimes intimate…  People had finally an opportunity to be something else than a risk score.  Of course over time more and more companies are finding ways to make use of that service, 140 characters at the time.

With a wider array of social details available and the development of Socialitics (analytics applied to social networks data), a fantastic source of information is becoming readily available.  When you explore professional connections within LinkedIn, you can infer “something” about any professional.  Digging deeper into the larger mesh of social networks, you can discover more about what they read, what they watch, who they spend time with, etc.  Despite the threat of identity theft, people are sharing more details than ever because they find value in it.  They can reach out to people that share the same interests or the same goals, professionally or personally, and develop a relationship that fulfills a real need.

I questioned Betsy as to whether Transparency, as one of the 4 pillars of Pattern-Based Strategy, was suddenly valued and appreciated as a reaction to our “digitalization” alone or whether it was also due to the fact that Social Media suddenly made it available?  Transparency may have been a value all along but only truly exposed with the explosion of social media.

Some pretty dark practices happen all the time in business unfortunately.  People abuse companies, companies abuse people, people abuse people or companies abuse companies.  Whether they use power or deception or anything else, the result is the same.  Over the past couple of decades, more people and companies have been increasing more conscious.  As a result some initiatives, going against pure greed, such as Sustainability have been nevertheless successful.  It is clear that one person alone cannot do it all.  The new power comes from collaboration across boundaries — companies, countries, etc.

Transparency is also like fuel for Social Media.  You get the full benefit of your participation when you actually participate.  If you are true to the network, if you are transparent, then you will be able to connect with people of the same vein and reach a higher level of exchange, more practical advice, more comfort or greater motivation.  Granted Deception could make its way into the system.  It reminds me of the Population Dynamics theories I learned in school…  The fact is that Social Media seems to be pretty effective at policing itself.

  • First, there is a fairly significant investment for a true participation.  “Faking it” seems like an unreasonable investment for pitiful results, not worth it.
  • Second, it is hard work to maintain a fake identity.  The risk of being uncovered is not small, so eventually those individual disappear.  Social Networks also actively develop mechanism to eject those people — Twitter launched verified accounts for celebrities mostly…
  • Lastly, social networks are dynamically shaping themselves: poor content and/or pure sales pitches without a little human value-added get quickly rated as such and attendance quickly drops

Transparency, wits, content have naturally become prime currencies on those Social Networks.

So…  Is the need for Transparency a consequence of Social Media dynamics?  Or is Social Media’s success a consequence of the need for Transparency?

1 + 1 = N

Being a Product Manager in my heart, I am always wondering what people truly want…  Some companies have been successful at deploying a community of users.  I actively participated in designing one for a previous employer but found true limitation in the technology or configuration that was chosen.  What I was quite happy to see though is that some users got involved.  A handful of passionate users took ownership of some technical questions.  I believe there is a huge potential for even more sparkling exchanges.  I am playing with this idea so stay tuned!

I have been impressed with the Transparency of companies that were open to share a lot of design details even to their competitors as part of industry user groups.  As I was told in “Ecole Preparatoire” (an elitist process to select students in France), the likelihood of a fellow student to take your spot are tiny, keep in mind that you will gain much more by supporting each other.  That quote from my teacher stuck with me (while students in other schools were busy stealing each other’s notebooks!!!).  I love to see that companies are adopting the same philosophy.  I love to see that Insurance companies that are direct competitors are willing to teach each other how to use Decision Management technologies because they will not compete on whether they design their Business Rules services this way or that way, they will compete on the strategies that the business rules execute.  Helping each other will increase each participating company’s skills at effectively leveraging the technology so that they can focus on content.  It is beautiful to see it happening in the real world.

This is not completely new as organizations like OMG have promoted competitors’ collaboration in designing standards for many years.  Social Media act as an amazing catalyst for more of that.  There is so much more we can accomplish when we get together…

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