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.
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