The claims process can, unfortunately, feel endless, leaving everyone involved stuck in a cycle of delays and frustration. Adjusters face stacks of records, claimants wait for updates, and carriers manage high administrative costs, all while inefficiencies drag out timelines and frustrate everyone. Every step in the process comes with its own set of hurdles. From tracking down medical records to completing assessments, it can seem like there’s always another obstacle to overcome.

It’s easy to feel trapped in an outdated system that just doesn’t keep up, especially with the rising number of claim denials piling on even more stress. In 2022, nearly 42% of healthcare providers saw an increase in denials. By 2024, that number had jumped to about 77%. This has made things even tougher for providers working to navigate the system and for patients waiting on much-needed answers. 

But it doesn’t have to stay this way. AI-driven solutions like Wisedocs can help untangle these challenges, simplifying the process, cutting timelines, and easing the burden for everyone involved.

How the Claim Life Cycle Operates

The current claim life cycle is a lengthy, multi-step process that often stretches to around 183 days. Here’s how it typically unfolds:

Claims Initiation

The journey begins with the claims adjuster, who initiates the process by requesting a medical assessment.This request is based on the complexity of the claim and the need for expert medical evaluation.

Record Upload  

Medical records are uploaded to a shared folder accessible to a Third Party Claims Vendor. These records may come from multiple healthcare providers, often in various formats and duplicate records, requiring careful organization and analysis.

Record Processing 

The Third Party Claims Vendor downloads, sorts, and summarizes the records. This step involves identifying relevant medical history, treatments, and any duplicate documents that could slow down the process.

Medical Assessor Review 

Once organized, the records are sent to the medical assessor through document sharing platforms like Dropbox or similar tools. The assessor then reviews the documents to prepare an independent medical evaluation.

Case Management 

The Third Party Claims Vendor coordinates the medical assessment through a legacy case management platform. This includes tracking case progress, managing deadlines, and ensuring compliance with regulatory requirements.

Report Preparation 

The medical assessor reviews the records and prepares a detailed report in another third party tool such as Adobe or Word document on their findings. The report aligns with state regulations or criteria specific to the line of business, ensuring the report is admissible in claim evaluations.

Report Submission  

The completed report is sent back from the assessor to the Third Party Claims Vendor via email or file-sharing platforms. Any missing information or inconsistencies may require additional back-and-forth communication.

Quality Check 

The Third Party Claims Vendor reviews the assessor’s report to ensure it meets requirements before forwarding  it to the claims adjuster. This step helps verify accuracy, completeness, and compliance before final submission.

Completion 

The claims adjuster receives the finalized report, concluding the lengthy process. They then use the medical findings to make informed decisions regarding claim approval, denial, or further investigation.

This process, while thorough, is time-consuming and resource-heavy. With so many manual steps and back-and-forth communications, it’s no surprise that delays can pile up, leaving claimants, adjusters, and vendors frustrated by the extended timelines.

A recent Insurance DataLab report found that complaints about the claims process make up more than 80% of all grievances against the top five insurers over the past five years. It’s a clear sign that this frustration is widely felt.

How Wisedocs Transforms the Life Cycle of a Claim

Wisedocs streamlines the claim life cycle into a simpler, faster workflow. By providing an automated platform, Wisedocs simplifies your workflow with automatic page deduplication, medical chronologies and medical record summaries. These tools arm claims professionals with the ability to process only what’s necessary and reduce errors. We can help you save up to 30% of time and resources, turning a months-long process into just days for a smoother, stress-free experience.

An Efficient Claims Life Cycle Helps Everyone

A smoother claim life cycle can truly change the experience for everyone involved. For claimants, faster resolutions mean less waiting and less worry. Carriers can breathe easier knowing inefficiencies are under control, saving time and money. Adjusters get the chance to focus on building stronger connections with claimants.

Introducing smarter technology, like artificial intelligence (AI), could open the door to substantial cost savings for insurers. Loss-adjusting expenses could drop by up to approximately 25%, and errors or “leakage” might be reduced by as much as 50%.

AI solutions, like Wisedocs, are transforming the claims cycle by reducing delays, minimizing errors, and creating a more seamless and hassle-free process for all parties.