InsureCo is a large Indian insurance company and is the one of the top three health insurers in India by its market share in health insurance. It accounts for about 20% of health insurance policies sold in India.

InsureCo is growing rapidly and its claim processing operations are a source of concern for its management and shareholders. In particular, the semi-manual processing of claims is causing

0.1. losses due to inaccurate medical verification

0.2. pricing leakages because of the complicated nature of hospital pricing

0.3. losses due to inaccurate application of policy rules

2. Vitraya’s solution for InsureCo

InsureCo adopted Vitraya’s solution end-to-end. Vitraya’s stack comprises -

2.1 An automated medical digitization and clinical judgment engine

The clinical judgment engine -

0.1. reads medical documents such as discharge summaries, lab reports, etc.

0.2. identifies medical terms

0.3. look for the context of usage of a medical term to classify the term as either a diagnosis, a suspected clinical condition, a symptom, a investigation, a pharmaceutical drug, a hospital service etc.

0.4. applies regulatory disease-treatment guidelines to ascertain whether the treatment is warranted

0.5. automatically applies one or more medical codes / ICD codes

0.6. approves or fires automated queries for the hospital to respond to

In summary, the clinical judgment engine replaces the doctor / paramedical team with an intelligent verification algorithm that is trained on millions of claims filed in the English language.

2.2 A policy smart contract

The policy smart contract appliers terms and conditions of an insurance policy real-time. Whether a policy has exclusions, treatment sub-limits, co-pay, benefits that differ according to the scale of pay of an employee the smart contract is able to handle all permutations and combinations. What is more, the result is available within microseconds. Details of the smart contract technology are available in our blog posts:

0.1. Standards for Health Insurance Policies Ship

0.2. First version Of hipml

2.3 bills digitizer and price applicator

Vitraya’s bill analysis and price applicator takes bill images in any format and is able to make sense of it. It performs the following functions -

0.1. segregates bill line items by ICD code for the disease whose treatment required that line item

0.2. confirms or corrects bill line items against the price agreed in the price schedule in the agreement

0.3. performs reconciliations in case of name mismatches between bill line item and price schedule

0.4. gives the insurer the ability to run special analysis, such as categorize the line items into special categories (e.g. drugs, surgery consumables, investigations, surgery etc. )

3. Implementation and impact

The system was piloted over 6 months and then implemented. Within 12 months of starting its scale up, Vitraya began automatically processing 30% of the claims of the insurer. The number is set to increase to 70% over the next quarter.

Vitraya has reduced total cost for the insurer by 15% primarily on account of improved accuracy (98%). Number of people in the insurer operations have reduced by 80%.

In its implementation, Vitraya worked with the insurer so its solutions could be integrated with their existing policy, workflow, and cash flow systems.