ESIS Case Studies | ProClaim

In early 2019, a physician insurance carrier that self-administered their medical professional liability claims for physicians across all specialties took a hard look at their results and found

• Escalating claim indemnity payouts
• Increased legal expense
• A 25% reserve redundancy
• More liabilities (reserves) than necessary carried on their balance sheet
• Significant claim staff turnover

Their efforts to improve underwriting policies and results were hindered by their inability to utilized data and analytics effectively. That, in turn, made it difficult to support a desired investment in risk control, underwriting, and innovative technology solutions to improve program results and member satisfaction. 

The client chose ESIS ProClaim as their new outsourced claim administrator and charged ESIS with two goals:

• Improve profitability, efficiency, and effectiveness of claim service delivery
• Support the company’s future state mission of delivering an exceptional physician experience during the lifecycle of a claim

ProClaim reengineered the client’s claim processes and policies, driving improved outcomes while simultaneously delivering great service.  

Over a 12-month period the ESIS ProClaim team:

• Reduced loss payouts by an average of 9%
• Reduced the program’s legal expense by 6% from prior years
• Shortened claim durations from 43 months to 32 months
• Reduced outstanding reserves by 22%
• Helped the client develop dashboards and share reports, metrics and insights
• Measure themselves against operating goals
• Improve underwriting
• Sort and share data by physician/practice to educate providers and improve risk management and patient safety

As a result of ESIS ProClaim taking over their claim management, the company showed an underwriting profit for the first time in several years. 

A global entertainment company had a large self-insured retention – and a problem with escalating legal expenses.  Their  general counsel identified recent increases in outside insurance defense legal expense as an area where better management would improve profitability.  Specifically, Counsel was concerned about poor management of assigned defense counsel on litigated claims by the incumbent TPA. Counsel believed the TPA was allowing claims to unnecessarily become litigated by failing to resolve legitimate claims and failing to detail claim denials appropriately. 

To help them reduce legal expenses,  the company  selected ESIS ProClaim as their new TPA.

ESIS ProClaim instituted our proactive early resolution approach, which includes litigation avoidance where  appropriate.  In addition, the ProClaim team understood that our interactions with the client’s guests are an extension of the guest’s overall experience. Our commitment to delivering an exceptional customer experience to the guests reinforced our client’s brand and their commitment to their guests, which further helped to reduce litigation and litigation expenses.

A one year look back of closed claims shows significant improvements in the client’s claims program:

• Defense cost savings of more than $800,000 for the total program.
• A significant number of claim files settled where the claimant was “pro se” and the ESIS ProClaim team avoided unnecessary litigation with prompt and fair negotiations.
• A significant number of claim files closed without payment even where the claimant retained counsel because the ESIS ProClaim team was able to  tender the loss to another responsible party and/or outright deny the claim and refute the plaintiff attorney’s theory of liability.  In addition, the ProClaim team was able to take an aggressive stand on defending the claim if a  suit was filed.
• A significant number of claims where the claimant was represented but plaintiff counsel did not file a lawsuit were resolved as fair offers were made by ESIS ProClaim.

A leading London syndicate and the following markets conducted an analysis of their 2019 claims for a miscellaneous professional liability program handled by their current TPA and found a number of issues:

• Multiple avoidable adverse claim outcomes,
• Consistently late delivery of loss bordereau’s to the brokers
• A significant amount of unsubmitted and therefore unpaid legal expenses that resulted in a high volume of complaints from defense counsel
• Overall lack of control of defense costs by their current claim administrator 

The markets agreed that a change was necessary to improve their results. After interviewing multiple TPAs, they selected ESIS ProClaim to serve as the their new TPA to manage both new and legacy claims. 

The ProClaim team delivered immediate improvements in program results. Within one year:

• 70% of the legacy takeover claims were closed
• 40% reduction in Open claims pending
• 27% reduction in Average incurred per open claim
• 15% reduction in average claim duration
• 76% of claims were closed in 180 days or fewer
• 165% closing ratio 

We start with a dedicated team of specialists — comprised of attorneys, nurses, and adjusters with an average of 25 years of experience.  The ESIS team’s expertise means they understand  how to

• Effectively control expenses
• Properly evaluate coverage
• Aggressively manage claims and litigation in a quick and proactive manner, and
• Providing the highest level of communication and customer service

The team is backed by a dedicated account and data management team.  In addition, ESIS ProClaim’s client-focused risk consulting practice helps clients effectively manage their risk management program. Our consulting and assessment services complement your ongoing safety and improvement efforts while addressing key areas of risk.