These claims programs may have
evolved over the years without a compari-
son of their practices and procedures to
leading industry standards. The programs
may have continued without the benefit
of additional products and services that
exist today and that continue to evolve. It
may have occurred because the organiza-
tion has not kept pace with the industry’s
ongoing updates and enhancements that
are designed to improve outcomes.
There are also some claim leaders
who believe that their industry or
environment requires a different claims
management approach. They believe
that are exempt from some of the leading
industry characteristics that many
insurers, third party administrators
(TPAs), and strong self-administered
programs try to follow. Some of the
reasons I have heard include:
1. We are a specialized industry and need
to operate/handle claims differently
2. We have clients that require us to man-
age the claims with their approval
3. The MGA or risk pool manages the
claims program because it knows best
what our clients want
4. We are too small to run our claims program like the larger companies/insurers
5. We operate in X state(s), which is a
very difficult environment
6. We are a public entity , and we don’t
need to follow the same standards as
insurers and corporations
7. Our procurement process requires us
to select the cheapest TPA/vendor
8. We cannot afford the claims system
that we need to manage our claims effectively and efficiently
9. We cannot find the right people in our
location to manage the claims effectively
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