Transforming Long-Term Care Claims with AI-Powered Solutions

The amaise agenticAI Platform and Product Suite revolutionizes the management of long-term care (LTC) insurance claims, delivering measurable improvements in efficiency, accuracy, and customer satisfaction:

84%

Increase in Efficiency

Streamline claims workflows with AI-driven automation.

Enhanced Understanding

Provide claims adjusters with deeper insights into medical, financial, and legal aspects of LTC claims.

10%

Reduction in Claim Payouts

Optimize settlements.

The Challenges of Long-Term Care Claims Management

Managing LTC claims presents several complexities:

High Volume of Claims

The increasing number of LTC claims requires efficient processing to meet demand.

Extensive Documentation

Handling large volumes of unstructured data, including medical records, care assessments, and legal documents.

Unstructured Data Formats

Dealing with handwritten notes, scanned documents, and diverse file types complicates data processing.

Subjective Evaluations

Assessing eligibility and care needs often involves subjective judgments, leading to variability in outcomes.

Fraudulent Claims

Identifying false or exaggerated claims is critical to minimizing costs and ensuring fairness.

Litigation Risks

Disputes over claim denials or settlements can lead to costly legal challenges and reputational damage.

Long-Term Care Claims in a nutshell

Long-Term Care (LTC) claims require careful validation of chronic illness, cognitive decline, or loss of functional independence. These assessments rely heavily on nursing notes, physician records, and evaluations that are often buried in lengthy, unstructured documents.

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As with disability claims, LTC adjudication can mirror workers’ compensation cases in complexity—and carries similar exposure to fraud and dispute.

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Determining eligibility and benefit triggers demands precision and consistency across documentation. Independent reviewers and care teams must often interpret historical records to make informed judgments.

our solution

The amaise agenticAI Platform and Product Suite

The amaise agenticAI Platform addresses these challenges with a comprehensive AI-driven approach to LTC claims management:

Automatic Document Organization

Effortlessly organizes all claim-related files—medical records, care assessments, legal documents—while eliminating duplicates for streamlined workflows.

Key Fact Extraction

Highlights critical information, such as medical diagnoses, care requirements, policy coverage, compliance risks, and legal exposures.

AI-Powered Insights and Recommendations

Provides actionable insights for decision-making, including risk evaluations, fraud detection, and settlement recommendations. Offers multiple perspectives—pro-insurance, pro-claimant, and neutral—to ensure balanced evaluations.

Preconfigured Question Sets

Customizable templates allow organizations to define specific evaluation criteria, ensuring consistency and thoroughness across all LTC claims.

Key Benefits

Optimized Claim Settlements

Ensures fair compensation while reducing overpayments or underpayments. Proven results include a 10% reduction in claim payouts, leading to significant cost savings for U.S. insurers.

Accelerated Claims Processing

Enhanced Fraud Detection

Litigation Risk Reduction