Blog | July 12, 2023

Trends in Insurance Claims: Medical Record Management and Early Case Resolution

The frequency and severity of claims in both senior living and long-term care continues to increase as noted in the 2022 General and Professional Liability Benchmark Report.  Providers, as well as their counsel and insurers, recognize early claim resolution reduces expenses.  Medical record documentation is key to this process, therefore effective and efficient management of the medical data is paramount.

In an April 2023 webcast, thought leaders from Marsh and Oliver Wyman expanded on the findings of the 2022 Benchmark Report.  With the projected loss rate trending at +2.1% for senior living and +3.5% for long-term care, it is important for providers to have robust risk mitigation programs in place.  The primary cause of loss continues to be falls at 78% in senior living (resident and non-resident) and 52% in long-term care.  Skin and wound claims are increasing on the senior living side with higher acuity residents and account for over 27% of LTC claims.  Fall management and wound care programs have a significant impact on paid indemnity and expenses.  Documentation associated with these programs, including, but not limited to, facility policies and procedures, results of regulatory and/or accreditation audits, staff training materials, correspondence with family members (written and verbal), and all documentation in the resident’s medical records, are all crucial components of prevention, mitigation, and defending claims and litigation.  Gathering and organizing these documents consumes significant resources.

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The longer it takes to close a claim, the more expensive the claim becomes.  Claims closed in one year averaged close to $46,000, while claims closed in five or more years averaged approximately $240,000, creating an incentive to resolve cases quickly.  There are many steps involved in managing a claim, starting with training to ensure quality documentation is completed by facility staff, then gathering information at the time of an incident, organizing and analyzing the relevant data, preparing reports, investigations with stakeholders, evaluating liability issues, determining an appropriate course for resolution, collaborating with counsel, and preparing for settlement/mediation/trial.

Insurance claims specialists, who typically have strong legal and/or insurance backgrounds, are usually the initial point of contact in the life cycle of a claim.  With the heavy focus on medical record documentation to support or refute the claim, claims representatives will benefit from the assistance of professionals with a healthcare background.  Experienced health information management, allied health, and nursing professionals can assist claims representatives by:

  • requesting and organizing medical records and other relevant materials,
  • evaluating the quality and completeness of the medical records,
  • assessing and integrating relevant policies and procedures,
  • preparing gap analyses and case summaries, and
  • delivering the medical records and medical analyses in an interactive database to support decision making by claims representatives and counsel.

Shifting medical record management functions will allow claims specialists to focus on case resolution, including early case valuation and assist in the overall defense strategy.  Contact Excelas to discuss your needs and how our approach to medical record analysis can assist you in ensuring the most effective deployment of your claims department personnel.

Case Summary
Medical Chronology
Early Risk Assessment

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