Scott Roller

💭 “What if I filed just one enhanced claim?” That’s what Jordan thought… until 𝗙𝗥𝗜𝗦𝗦 𝗠𝗲𝗱𝗶𝗮 𝗖𝗵𝗲𝗰𝗸 woke him up. Literally. In Claimsburg, fraud doesn’t stand a chance. With image manipulation detection, metadata analysis, and document integrity checks, 𝗙𝗥𝗜𝗦𝗦 𝗠𝗲𝗱𝗶𝗮 𝗖𝗵𝗲𝗰𝗸 helps insurers catch deepfakes before they turn into payouts. From fake iPads to "adjusted" invoices, Jordan’s dream scam quickly turned into a digital nightmare. 🎬 Check out this short animated video and see what happens when pixel-perfect fraud meets 𝗙𝗥𝗜𝗦𝗦 𝗠𝗲𝗱𝗶𝗮 𝗖𝗵𝗲𝗰𝗸. #InsuranceFraud #DigitalForensics #ClaimsInnovation #FraudDetection #Insurtech

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🚨 CMS is accelerating RADV audits — and fast. Sampling for Payment Years 2020–2024 will begin June 16, 2025. That’s just over two weeks away. This follows CMS’s recent expansion of the RADV program to include all eligible MA contracts annually, with extrapolated recoveries based on small sample audits. The risk? Plans that haven’t submitted risk adjustment data corrections (“closed period deletes”) could face significant financial liability. At Wakely, we’ve built a tool that helps you: 1. Flag high-risk diagnoses likely to be audited 2. Prioritize record reviews 3. Reduce extrapolated recovery exposure The timeline is tight. If your team needs help preparing, we’re here. #MedicareAdvantage #RADV #HealthPlans #CMS #RiskAdjustment #HealthcareAnalytics

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Efficiency. Experience. Engagement. Insurers using outsourcing are seeing gains across all three and it’s not by accident. NelsonHall’s latest data shows how smart execution changes everything: https://sps.news/FG4S8L

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When underwriters spend 10-20% of their time reading and analyzing certificates, insurers miss focusing their highly skilled talent on areas where they can add value and make a real difference for their clients. Underwriting automation fills in the gaps, so people can spend time doing what they do best – analyzing risk assessment with a human perspective in a way a machine cannot. Watch the whole interview with Cortical.io and one of our own highly skilled underwriters, Chelsea Wild, to hear why we're both passionate about human-centric underwriting: https://lnkd.in/dWtcMHYt

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PEOs play a critical role in supporting small and medium-sized businesses but managing workers’ compensation claims brings unique operational and legal challenges. From handling diverse risk profiles and fraud detection to navigating limited control over client worksites, PEOs face a complex WC landscape. In a recent guest post, Pragatee Dhakal, Esq., Director of Claims Solutions at CLARA Analytics, explores how AI is emerging as a game-changer for PEOs. Read the full article to see how AI is helping PEOs mitigate risk, control costs, and improve outcomes: https://shorturl.at/ENYV9 #WorkersComp #PEOs #InsuranceInnovation #AIinClaims

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Every day insurers navigate broken bridges through manual handoffs, scattered systems and siloed processes. These gaps slow down decisions and increase compliance risk. #NewgenONE Agentic Insurance Journeys transform this landscape by connecting every step with specialized AI agents. From underwriting to claims it is one smooth connected experience that drives speed, accuracy and better outcomes. Learn More: https://lnkd.in/gAjTR77p  #Newgen #AIFirst #AgenticInsuranceJourneys #Underwriting #Claims #AIAgents #Insurance #Automation #DigitalTransformation

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In today’s uncertain environment, understanding your claims landscape is more critical than ever. Blue[i] Claims provides real-time visibility into your claims data, helping you pinpoint high-impact drivers and optimize your risk management approach. Learn how tailored insights can support your organization’s financial health. https://bit.ly/4nG66o4 #RiskManagement #claims #DataDriven

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Building or buying a Claims Documentation Platform is one of the biggest decisions claims leaders face ⚡ Our Buyer’s Guide walks you through how to weigh the pros and cons of each path. From ROI comparisons to compliance and scalability needs, this guide helps you evaluate your options with clarity and confidence. Cut through the noise in AI claims tech and see what matters most when choosing the right solution for your team. 👉 Download the Guide today https://hubs.ly/Q03H6yk00 #Wisedocs #BuyersGuide #ClaimsProcessing #ClaimsLeaders #Insurtech #HumanInTheLoop

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I finally found the CMS FAQ in response to the NAIC Commissioners questions. I wish this was disseminated more widely, I haven not seen this anywhere. Not all answers are satisfying, but definitely progress What criteria does CMS use to determine whether a network change is “significant” after receiving notification from a plan of a network change? Are employer-sponsored plans held to the same standard as other Medicare Advantage (MA) plans when there is a network change? How long does it take to make the determination that a network change is “significant”? How are plans notified of the need to send communications to enrollees after a provider network change? Some Medigap plans are providing $0 commissions for guaranteed issue Medigap plans. This appears to be an attempt to discourage the sale of plans to consumers the plans believe to be worse risk, is this allowed? Some MA plans are providing $0 commissions for new MA sales. Is this allowed? When an MA enrollee’s provider(s) no longer contracts with the MA Plan, can the enrollee switch back to traditional Medicare and enroll in Medigap on a guaranteed issue (GI) basis so that they can retain their provider(s)? If CMS does determine a "significant" event has occurred, where the consumer would qualify for a special enrollment period with Medigap GI rights, how are the Medigap GI rights communicated to the insurer and the consumer? The consumer is notified that the MA plan they had in 2024 will no longer be available in 2025 and the consumer has been cross-walked to another MA plan offered by the carrier. If the new plan has a tighter network and the consumer does not want that plan, can they switch back to traditional Medicare and enroll in Medigap on a GI basis? The consumer is notified that the MA plan is leaving their service area and they must switch to another MA plan. The alternative MA plan options have a different network or the consumer simply does not like the other plans. Can they switch back to traditional Medicare and enroll in Medigap on a GI basis? For individuals eligible for a special enrollment period with Medigap GI rights, which Medigap plans are available? Can states be notified when a MA plan changes their network? Can states be notified (maybe a database that can be sorted by state and county) of which plans are deemed to have a “significant” provider network change and which enrollees have an SEP? This would help the states answer questions and know how their Medigap markets may be impacted. Have there been GI rights available when using an MA SEP in the past? When determining whether a provider termination is “significant”, does it matter to CMS whether the MA plan terminated the provider from their network or if the provider terminates their contract with the MA plan?

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Claims workflows need an update to improve efficiency and enhance customer experience. Agentic AI can help free adjusters to focus on higher value tasks across the entire claims life cycle. From first notice of loss to settlement, agentic systems are opening up new possibilities—streamlining tasks like triage, coverage validation, and communication handoffs, while improving consistency and turnaround time. David Kuhn and Raghavendra “Raghu” Aithal explore how this AI-powered approach can reshape your claims process. https://lnkd.in/eCur2z5G #ClaimsInnovation #AIinInsurance #InsuranceTechnology #ClaimsProcessing #AgenticAI #DigitalClaims #ValueMomentum

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More insurers are rethinking how they manage print and mail—and for good reason. In-house operations can be costly, complex and hard to scale. We’re teaming up with Madison Advisors for a live webinar and Q&A to break down what’s driving this shift and what carriers are gaining by outsourcing. 👉 http://spr.ly/60434t48x 🗓️ July 16th | 1 PM ET #PrintAndMail #CustomerCommunication #InsuranceOperations #CX

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For MGAs, growth and underwriting discipline aren’t opposing forces—they’re deeply connected.    MSI’s President of MGA Solutions, Amy B. Carlisle, shares with Insurance Business America how MGAs can scale while maintaining profitability, emphasizing the role of talent, technology, and underwriting rigor.   Read more 🔗 https://lnkd.in/gn65CrSr   #TheBaldwinGroup #ProtectingThePossible

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Insurance has a customer loyalty issue. Delays in claims and outdated payout experiences are costing insurers in trust and retention. The fix begins with optimizing payments: ✅ Faster claims processing ✅ Automated processes ✅ Real-time payouts Payments aren’t just a back-office function, they’re a competitive edge. Read the full report on the state of the insurance industry and how insurers should respond here: https://lnkd.in/exR_hXgR

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WTW’s Radar now enables insurers to seamlessly incorporate Verisk's ISO Electronic Rating Content™ (ISO ERC™), reducing the time to utilize ISO updates from months to just minutes. Analyze, refine, and deploy ISO-based pricing models faster than ever before, creating room for sharper market responses. ➡️ Learn more about the partnership: https://ow.ly/I1Bc50WjMMC ➡️ Discover how Radar is transforming insurance analytics and deployment: https://ow.ly/Awr950WjMNc #InsuranceInnovation #EfficiencyInInsurance #SpeedToMarket #WTWRadar

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