Claims adjudication


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Milliman’s clinical consultants conduct operational audits of claim teams for health insurance companies and third-party administrators (TPAs). We carry out on-site visits, staff interviews, and retrospective data analytics to identify areas for efficiency improvement as well as cost saving areas. Such due diligence audits help insurance companies optimise their operations. We also help develop IT system checks to identify potential areas of savings.

To help reduce loss ratios, Milliman’s clinical experts conduct retrospective electronic audits and focused sampled audits of claim files to identify the extent and scope for cost savings. We conduct a series of contractual, cost, and clinical checks using evidence-based clinical reference criteria and our experience in the health payer and provider industry to identify suspect claims.

Pilot claim audits help insurers identify cost savings

In pilot claim audits with multiple TPAs and insurers, Milliman’s clinical team has been able to identify potential overpayments and excessive or unwarranted billed items. Insurers and TPAs found potential cost savings of 4% to 8%, of which 2% to 4% savings were realised. For a portfolio with Rs 100 crores of claims paid, this amounts to a savings of Rs 2 crores to Rs 4 crores.

Customised clinical rules and logic

Milliman’s clinical consultants have developed customised clinical rules and logic into claim systems for three health insurance companies and one TPA in India.

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