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Help! Claims Review Shredded My Xactimate Estimate

The DYOJO

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Article & video - Help for estimators dealing with claims review and rejections.

We discuss:
  • The elements of Insurance Claims 101.
  • Common rejection items that are easily addressed and yet continue to be hang ups for restoration companies large and small.
  • Telling the story of the loss through Xactimate opening statement, line items and F9 notes.
If you write a sloppy estimate and you are not learning from prior mistakes, expect to get rejected. At the same time, whenever the carrier or program initiates are rejection of an estimate this should be a time where the restorer reviews whether the objections are legitimate. This invitation to review the merit of the estimate is also a time when the estimator should review whether legitimate line items were missed in the prior submission.

See also The DYOJO article on the Habits of Xactimate Estimating Success

So, how do we gain ground on the claims review process? Here are some suggestions to start tracking data to inform decisions and find resolution:
  • Do you review your rejections for trends? You can do this as a team or you can do this as an individual estimator. You can download the attached PDF Tracking Claims Review Worksheet (see end of article) or you can develop your own system.
  • Change your mindset. Above we framed the claims review process in wins, losses and ties. With this win-loss mindset our sample restoration company was not winning. What if we change our mindset to founded (reasonable review queries based upon the standards, practices and carrier guidelines), unfounded (contradictory to standards, practices and carrier guidelines) or in the gray area (subject to interpretation). If you download our worksheet you will notice these are the categories.
  • Change your process. The status quo is to complain about the system. If you are approaching your profession with a growth mindset you will work to find solutions to your issues. Start by tracking your rejections so that you can make decisions based upon objective data rather than your collective-subjective opinions.
Check out The DYOJO video on Surviving TPA Rejections
 

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