Prioritizing Long-Term Care Claims

The Challenge

Knowing when, or if, a long-term care claimant was likely to recover would allow more efficient clinical review scheduling. The goal of this project was to improve the management of long-term care insurance claims by anticipating changes in claim payout rates that occur as patient conditions evolve and caregivers provide expanded care.

The Solution

After consulting with the client to understand how claims are paid out over time, the immediate area of opportunity was to prioritize resources for claim review by anticipating escalating claim invoices that would likely remain high for many months. Many factors were such as nuanced details of invoice history, changes in care settings, policy limits, and past actuarial assessments were considered. Significant crosschecks were needed to remove the impact of time, macro-economic factors and management. The production model successfully identified claims that will expand in payout, with 77% of such claims in the top three (leftmost) deciles.


Our client was better able to serve their customers’ changing needs by identifying cases likely to benefit from proactive intervention by providing helpful recommendations to the caregivers for additional patient services before decisions on the cases were finalized. This improved the patient care and management of long-term care claims.

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