Working closely for 5 years with claim supervisors, handlers and support staff of the nation's largest Property and Casualty Company, Blackstone Bay professionals identified the following key challenges to serve as the basis for creating a viable and complete claims processing solution:

• Inefficient workflow management. Even in situations in which the bill is imaged to electronic format, the image is manually reviewed and routed to another individual, who evaluates the information for completeness. If data is missing, this person must retrieve other documents or images and manually fill in the blanks on the original document. This updated image is then sent to the next stage in the process, where other decisions are made, images added, and the file is passed on and on until it is ultimately resolved many steps later, often after many redundant procedures involving excessive claim handling personal.

• Constantly changing industry regulation and practices. Claim reviewers are forced to remember rules and where to look up the rules. Even when jurisdictional rules for the various states are already programmed into existing systems, a number of rules and exceptions still need to be applied by the individual reviewer looking at the claims. This problem is compounded by large P&C companies moving to centralized claims processing centers, where multiple state rules and regulations need to be remembered and applied by individual claim handlers.

• Poor understanding of billing policies. Particularly in PIP states, auto insurance companies are being required to offer consumers an increasing number of medical coverage plans. In Colorado alone, P&C companies must provide 84 variations of coverage. This puts a huge burden on claim handlers to be familiar with the various deductions, co-payments, and coverage specifics of each plan.

• Incomplete or unclear payment policies. Nearly 65% of all claims, those involving routine procedures with low costs, could be processed automatically and with minimal, if any, human review. However, the ability for claim handlers to decipher these claims is limited by the cumbersome data associated with paper files, and in the case of scanned bills, the inability of the system to distinguish between simple and complex situations.

• Inability to identify double-billing & duplicate payments. Providers of healthcare are often liable for multiple billings of a single procedure. These double-billing instances often go unnoticed due to similar procedure descriptions of the same service and the fact that claim handlers are handling up to 200 claims at one time, thus inhibiting their ability to recognize these scenarios. The result is duplicate payments by insurers, costing P&C companies millions of dollars.

• Insufficient fraud review capabilities. Due to the high number of claims being processed by any one handler at any one time, in addition to the quick turn around time required on settling a claim, the ability to recognize or investigate fraudulent signs is extremely limited. Typically, insurance carriers have a 30-day period to notify the insured of services rendered. If the insurer is unable to conclude its investigation within the 30 days, the insurance company is deemed to have waived its right to refuse payment of the claim. Furthermore, current systems provide limited capabilities to detect fraudulent signs, such as unusual gaps in treatment, invalid treatment codes and unrecognizable health care providers

  To identify, understand and meet these challenges, the design and ultimate functionality of ePIP was predicated by years of research, development and continuous refinement to the end product.