The Teleunderwriting Disconnect
Hank George, FALU, CLU, FLMI
August, 2007 • Teleunderwrtiting Essay 7
Realizing Reasonable Expectations
In 2009, at least one U.S. insurer will celebrate 20 years of teleunderwriting. A handful more will follow in the ensuing years…but the fact is that the vast majority of insurers now doing teleunderwriting started after the turn of the millennium and many are still sorting their way through issues that need to be addressed to optimize success.
While we have cited many reasons for embracing teleunderwriting, the two that stand out in most peoples’ minds are:
- Reducing dependence on medical records
- Shortening application-to-issue cycle time
And well they should, considering the adverse implications of failing to deal with these knotty problems.
As this underwriter works with clients in tracking the success – or otherwise – of their teleunderwriting initiatives, as well as through dialogue at teleunderwriting seminars and underwriting study groups, it is clear that both goals can be frustratingly elusive.
Companies tell me that while they have reduced medical record ordering somewhat, the magnitude of improvement has not met their expectations.
Some report no decrease and a few have even had the seemingly paradoxical result of seeing medical record-seeking increase.
No improvement?
An increase?!
How is this possible?
We’ll get to the “how”…and to what can be done about it…in a moment.
As regards turnaround time, there have also been more than a few new entrants into teleunderwriting who have been vexed about something less than awe-inspiring results.
No doubt a major factor bearing on suboptimal turnaround time relates directly to failed efforts to decrease the pursuit of medical records, given that the slowest prevalent requirement is invariably the APS, PMAR (or whatever acronym is fashionable in your realm to demarcate medical history reports).
Sadly, the odd carrier has even opted to back off from teleunderwriting, lest a track record of failure to achieve these expectations come full circle to his/her doorstep in the most inhospitable manner!
Medical Record Dependency Syndrome
Consider the following explanation for how the tenacious persistence of MRDS (medical record dependency syndrome) might be due to the synergistic effects of two compelling forces.
Force # 1
Underwriter Mindset Most veteran underwriters were “schooled” in our profession at a time when medical records were hailed as the cornerstone of risk assessment.
Audit-mediated chastisement (and its attendant consequences) in those days was more likely to be driven by concern for the APS they did NOT get, not for getting too many!
And as these MRDS “sufferers” trained, mentored and audited junior underwriters and took great pains to ingrain staunchly “pro-APS” mindsets.
Before we proceed with this line of reasoning, let’s be crystal on one point:
Medical records are a vital asset in every domain of mortality and morbidity underwriting!
When we speak of the “pro-APS” mindset as a barrier to progress, a critical distinction must be made between essential vs. non-essential medical records.
One does not underwrite major cardiac disorders, invasive cancers or systemic lupus based solely on drilldowns!
One does not forego details of a “routine medical examination 18 months ago” on a 69 year old in favor of cryptics comments about the results!
Perhaps an example will help clear the air on this point:
One insurer with over 15 years of sustained teleunderwriting experience reported that at the point of transition from traditional underwriting, they got medical records on 35% of insurance seekers.
This dropped precipitously to 5% early on in teleunderwriting. It became apparent that their underwriters took the mandate “if you don’t think you need it, don’t get it” to the point of inducing night terrors among their actuaries! Clearly, the underwriters had gone overboard and put the company at risk for significant excess mortality by ordering too few APS’s.
At last report, they were comfortably situated at 15%, getting what they really need and acting in a timelier and less expensive manner on those cases where teleinterview content made taking action, sans an APS, appropriate.
Some years ago, I was asked to speak to an insurer’s underwriting team just prior to the roll-out of teleunderwriting. As I gushed on about how high quality drilldown questionnaire content would allow them to make many decisions on cases where they would previously have consigned the file to virtual purgatory while tracking down physician reports, one could read their reactions in their body language!
One fellow remains in my “mind’s eye” to this day.
He was bearded, fifty-something, sitting in the front row, glaring, jaw clenched, arms folded tightly across his chest.
Diagnosis: Inoperable MRDS.
Subsequent events suggested MRDS in this shop* was quite probably an airborne virus!
*“Shop” is an American synonym for “underwriting department” which we old codgers take every opportunity to nostalgically perpetuate!
The point here is that MRDS is a potent vector of negative energy directed against your efforts to put an end to the ordering of unnecessary medical reports.
Force #2: Underwriting Manual Configuration
Medical underwriting manuals are driven by clinical diagnoses.
Check it out…see if this isn’t an accurate statement as regards your manual(s).
A proposed insured has been given a clinical diagnosis of “vasovagal” or “carotid sinus” syncope and, voila, the manual provides a (hopefully) clear set of guidelines for sorting the best and the worst from the rest.
Whereas competent drilldown questioning of syncope should yield a bounty of instructive information, the applicant’s recollection of the precise diagnosis (if any) rendered by his physician is typically something short of definitive!
The underwriter is therefore at a crossroad of sorts when trying to use their manual.
At this point he/she can either appraise this bounty of drilldown information so that a cogent decision can be taken on a significant portion of syncope cases…
…or, succumb to the traditional mindset and deem medical records inherently necessary to take appropriate action.
The difficulty of taking the high road (making as many decisions as possible based on teleinterview information without ordering an APS) is compounded by the studied ambiguity of the manual guidelines for syncope in the absence of a clinical diagnosis:
“RFC” being “rate for cause” and “IC,” of course, is the “mother” of all useless advice: “individual consideration!”
Ipso facto: if I don’t KNOW the cause based on the bits of salient detail disclosed via drilldown questioning, then what choice do I have but to shag down medical records?
The very same puzzlement awaits the underwriter in a wide range of risks demarcated by both prevalent (palpable lymph nodes, chest pain) and less uncommon (gynecomastia, pruritus ) signs and symptoms.
Underwriters – at least in the Western world – are not physicians.
And even when they are doctors, this fact hardly guarantees that a satisfactory decision-making comfort zone could be realized in many of these scenarios…in the absence of manual guidelines that do a thoroughgoing job of sorting the implications of drilldown-derived details.
Hence the negative synergistic impact of forces 1 and 2 culminates in the failure to realize significant reductions in medical record ordering in a teleunderwriting environment.
An impact I call “the teleunderwriting disconnect.”
Dealing with the Teleunderwriting Disconnect
We did a continuing education course on SYNCOPE. To my knowledge, it was the first underwriting-focused comprehensive examination of syncope that not only reviewed insurability issues in the context of clinical diagnoses but also came to grips with the comparative significance of drilldown-extractable details in the absence of a known diagnosis.
We will do a similar course, this one on Underwriting Headaches, in our 2008 CE program.
Unfortunately, the ideal format for continuing education is not the same as how one would best present information to facilitate decision-making on actual cases.
In a teleinterview drilldown, we expect to get at least some and ideally all of the following nuggets of information related to any given impairment:
- What were the symptoms?
- When did they commence and when was the last time they were experienced?
- What tests did the doctor do and what did he/ she say were the results?
- Were you referred to a specialist?…and if so, what is their specialty?
- Were you seen in an emergency department for this problem?…and details if yes.
- Were you hospitalized as an inpatient?…and details if yes.
- What type of treatment did the doctor give?…and then expanded information here, especially if the treatment was medication.
- Did the doctor recommend any tests or treatments that have not been undertaken?... and if yes: what were they, are they scheduled; if so, when and if not, why not?
- Did the doctor advise you to limit your activities and/or have you had to do so yourself?
- Have you used any alternative and complementary remedies?...and if so, which ones?
At least 10 nuggets of useful information, in some cases significantly amplified with further questioning.
But how do these nuggets connect?
Is a particular test strongly suggestive that one particular diagnosis was uppermost in the mind of the physician?
Do the interventions and recommendations support this presumption?
Are some of these nuggets actually RED FLAGS?
And if yes, how many…and how do they come together to compel immediate adverse action vs. pursuit of medical records?
Conversely, is the portrait of the risk based on this mosaic of nuggets compatible with making an underwriting decision in lieu of further underwriting?
Hopefully it is becoming clear here that what the underwriter really needs (if we are to realize the full potential of drilldown content) are – for want of a better word – sign and symptom “paradigms.”
Paradigms which enable the underwriter to weigh the relative significance of each piece of the puzzle, and thus, to ”connect the dots” and make a decision.
Is it possible to fashion such paradigms in a way that facilitates decision-making in “sign and symptom” scenarios…yet avoid encumbering the time-pressured underwriter with a morass of detail?
Based on my research in preparing the syncope CE course and teaching “Signs and Symptoms of Disease” for over a decade on behalf of clients of my last employer, I know that the answer is yes.
Thus, in the months ahead we will manufacture a core set of these paradigms for underwriters worldwide…
…because until insurers effectively resolve the teleunderwriting disconnect, it is unlikely they will enjoy sustained reductions in (avoidable) APS ordering and finally have an antidote to that insidious adversary of progressive risk management: the medical records dependency syndrome!
DISCLAIMER
This essay was written for informational purposes only. Hank George and Hank George, Inc. do not recommend or endorse any specific business practice or procedure discussed herein. All business considerations concerning matters covered herein should undergo proper and sufficient scrutiny by appropriate management personnel of the companies involved prior to implementation on any basis. © 2009-10 Hank George, Inc.
