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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 guidelines.

Pilot claim audits help insurers identify cost savings

In 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.

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