A key factor driving EvolutionIQ’s successful Series A funding is that the insurance industry is in the midst of a dramatic, once-in-a-generation change in how it manages claims. It’s all about applying artificial intelligence to drive actionable insights.
As TechCrunch reports: “Informed by its predictive algorithms, EvolutionIQ spotlights dozens of claims from tens of thousands that are most likely to have the greatest outcome for claimants, carriers and clients. EvolutionIQ also monitors open claims to guide workers to those that require more attention or new actions, including claims that have potentially fallen through the cracks.”
The story notes that “processing claims at scale presents a challenge for insurers, particularly where the claims entail factors like complex underlying health conditions. According to data from the National Association of Insurance Commissioners, the second-most common complaint that insurance customers made in 2021 was claim delays, ranked only after unsatisfactory settlement offers. The pandemic placed an additional strain on insurers, with an RGA survey finding that claims acceptance rates for permanent disability, critical illness and long-term care have been minimal over the past two years.”
To address the challenge, EvolutionIQ works with insurers to analyze claimant data and third-party information to identify “high-opportunity” claims, specifically those involving bodily injury.
“EvolutionIQ assists insurance professionals in improving claims handling through insights uncovered by analyzing historical claims data,” CEO and co-founder Tomas Vykruta explained. “With our decision intelligence platform, claims teams can recoup lost time and streamline processes. Our software allows front line operators to make more informed decisions and focus their energy on high-potential claims. For managers, we’re able to identify claims blocks that need further investigation and those that are easily resolved — and then provide guidance to make it happen.”
The key to AI adoption, he said, is “building ‘explainable AI’ systems in tight collaboration with the users. There [must be] two systems: one that makes predictions [and] one that explains the forecasted outcomes in [plain] language.” The explainability approach makes it clear to the adjuster what sort of factors led to the platform’s decisions.
How it Works
EvolutionIQ’s platform evaluates the history of claims, asking questions such as, “Is this a claim on which we can take action?” and “Is there going to be an outcome that makes sense?” TechCrunch writes. “A claims adjuster, who may have hundreds of cases active at a time, can better understand short-term disability, long-term disability, workers comp and property and casualty claims; identify the most actionable opportunities; and see the results in the context of new data and events.”
Tom pointed out that “claims are really incredibly complicated because you’ve got these narratives that are open for many years. Some of these claims are 15 or 20 years old. They have as many as 30 to 40 medical diagnoses. The insurance industry can’t solve this comprehensively. What this has led to is just incredible waste in unnecessary payments. Examiners [may] look at the last couple of pages of notes and generally, they don’t take any action at all.”
TechCrunch underscored that “informed by its predictive algorithms, EvolutionIQ spotlights dozens of claims from tens of thousands that are most likely to have the greatest outcome for claimants, carriers and clients. EvolutionIQ also monitors open claims to guide workers to those that require more attention or new actions, including claims that have potentially fallen through the cracks.”
“Claims examiners want to focus on the cases that have the greatest impact on customers and carriers,” Tom added. “But claims handling involves archaic and manual processes that require examiners to review too much information or to evaluate data on their own, despite the fact that each claim involves multiple people and systems. Therefore, we built a decision intelligence platform that acts as an AI-enabled copilot to identify high-opportunity claims early in the lifecycle and cases most likely to be referred to adjusters.”
“The way Vykruta sees it, EvolutionIQ’s value proposition is reducing overpayment, waste and longer claim durations. Insurance carriers’ teams are stretched thin by rising claim volumes, and the systems responsible for making management scaleable actually compound the problem, he asserts — forcing examiners to make tradeoffs that lead to slower decisions and mistakes,” TechCrunch reports.
“Claims can last years, many worth six figures, and involve hundreds of pages and many formats (structured and unstructured) constantly flowing in … We actually give time back to claims organizations by identifying the cases that don’t need to be addressed and can be set to be resolved,” Tom said. “[We’re working with] the top disability carriers, property-casualty carriers and third-party administrators including Reliance Standard, Principal, Sun Life, Argo Group, Matrix Absence Management and FullscopeRMS.”
Added TechCrunch: “EvolutionIQ — which was cash flow-positive in 2021 — will spend the bulk of the new capital on expanding its engineering, data science, product and customer success teams. Customer acquisition will also be a focus going forward, he says, as EvolutionIQ explores new and emerging categories of insurance.”