Got Workflows? How to Audit for Compliance

Transcription

1 Applied Systems Client Network SEMINAR HANDOUT Got Workflows? How to Audit for Compliance

2 Got Workflows? How to Audit for Compliance Prepared for ASCnet Applied Systems Client Network 801 Douglas Avenue #205 Altamonte Springs, FL Phone: Fax: Copyright 2009 by Applied Systems Client Network, Inc. (ASCnet), 801 Douglas Avenue #205, Altamonte Springs, FL Protection claimed in all forms and matters of copyrightable material and information now allowed by law or hereafter granted including both electronic and conventional distribution of herein products. Reproduction or transmission unless authorized by ASCnet is prohibited. All rights reserved. Specific product information regarding Applied Systems The Agency Manager and Vision, as well as other products copyrighted and mentioned within (ex: Microsoft, Excel, etc.) are the product of the individual company and no endorsement or ownership of product should be implied by its mention and use. All workflows are suggested and common workflows. Users of this material agree that ASCnet cannot be held liable for any omissions or errors within the guide. Original Author: Jennifer Godwin AIS Technology LLC Updated By: Jennifer Godwin AIS Technology LLC Sept 2009 Jennifer Godwin AIS Technology LLC Aug 2008 Target Audience: Accounting Account Executive Non-Insurance Accounting Customer Service Representative Administrative New Producer X Principal Experienced Producer X General IT Human Resources X Other: Managers, Quality Control Seminar Type: Management, Reports Seminar Level: Intermediate Level: An Intermediate level class takes the concepts originated from a basic level course, and adds more layers or parallel concepts. For functional courses, these classes will require the participant or attendee to have some basis to work from as they are learning new facets of the agency management system or software program. September,

3 Got Workflows? How to Audit for Compliance Class Description: Once workflows are created, to understand what is involved in auditing for compliance and how to utilize TAM reports and searches to gather the necessary data to audit. Learning Outcomes: Reasons Why Audits Are Necessary Element to Workflows Who, How & When Audits Should be Conducted How to Use TAM Reports/Searches to Conduct Audits Assumptions: This seminar is based on the following TAM Version 10.3 Microsoft Word Version 2007 Table of Contents Auditing Your Workflows... 4 Audits What to Consider??... 4 Suggested Methods for Auditing:... 5 Managers Audit Employees... 5 Employees Audit Employees... 5 Third Party Audit Employees... 5 What to Audit???... 6 How, When, Why... 6 TAM Reports for Audit Purposes... 8 Activity Report... 8 Exceptions Report... 9 Transactions / Production Report... 9 Search Customers Policies Current / Applications... 9 DATA INPUT AUDIT - Audit the following areas: BILLING SCREENS: Yes CLAIMS INPUT ACTIVITY / TRANSACTIONAL FILING ACTIVITY CATEGORY(S): September,

4 Got Workflows? How to Audit for Compliance Auditing Your Workflows Once your agency has written workflows and those workflows have been implemented, the primary manner to ensure that the workflows are being complied with is Auditing both client files and your agency management system. Auditing verifies that actions taken to sell and service insurance to your clients have been documented properly in your agency management system. Auditing serves as a quality control check for your agency allowing managers to know how much of your management system s data can be relied on. Auditing: o Helps identify & reduce exposure to E&O o Teach consistency o Discover areas for improvement Audits What to Consider?? In order to have effective auditing, expectations need to be set and all staff members need to be aware of those expectations. Those expectations are outlined in your agency s written workflows. Once implemented, initial audits of data utilizing Activity Reports can and should be conducted to ensure that staff is entering correct activities and that the detail of those activities is entered as outlined in your agency s written workflows. However, your agency s written workflows should be implemented a minimum of six months prior to conducting a true client/file audit. This will provide a timeframe of both sales and service actions to review proper timeliness as well as documentation of those actions. Set a date for Audit to begin notify CSRs of that date. September,

5 Got Workflows? How to Audit for Compliance Suggested Methods for Auditing: Managers Audit Employees Managers auditing staff they supervise is usually the first method agencies consider. It seems automatic and a way for managers to determine if there are any performance issues. While this is true, most managers, especially in smaller agencies, wear more than one hat and often times may handle a book of business and/or have other duties in the agency in addition to managing staff. Time becomes the biggest issue with this method of auditing. Employees Audit Employees Most agencies cringe at the thought of employees auditing each other BUT this method can work! The key to employees auditing employees is a checklist of items to audit and the scope of the audit not extending beyond that checklist. Employees auditing employees provides an excellent cross-training tool and you just might find that the staff is more conscientious themselves when following the workflows since they are having to audit other staff members. Third Party Audit Employees Bringing in a consultant to audit your staff can be a smart move provided you have set guidelines for the auditing process. Do not let the consultant use auditing of your workflows as an opportunity for them to find other work for themselves. Make sure you obtain a quote for their services for the audit guidelines you propose. September,

6 Got Workflows? How to Audit for Compliance What to Audit??? Accounts should be Auditor s Choice Based on an employee s book of business, select accounts that represent a cross section of the customer s they handle. Do not accept offers of sacrificial lambs! There should be no advance warning to the CSR of what accounts will be audited. Even if given advance notice, a CSR or other staff member cannot clean up an account. The evidence of many activities added on the same day will outline the clean up attempt. Your goal is to determine if the workflows were followed using proper documentation in a timely basis. Determine a minimum number of accounts per CSR to audit. Suggest at least three to five accounts per CSR. Choose accounts recently renewed to best evaluate the renewal process. This will give you the opportunity to review the submission/marketing process as well as the timing in binding coverage and issuing evidencing documents. It will also provide an opportunity to review service functions such as changes, interim certificates, etc. How, When, Why There are basically three levels to an audit and your agency should determine what levels to include in their auditing process. The levels are: Quality of Agency Management System Data this level reviews customer, billing screen and application detail to verify that minimum standards are being met and that correct values are being entered as well as correct formats used. Compliance with Workflows this level reviews the actions taken to sell & service insurance for a client to make sure those actions are documented & timed according to the agency s written workflows. Proper Insurance Coverage Provided this level reviews actual coverage afforded in the customer s policies. Verification of correct exposures on all policies as well as the limits of the coverage afforded and proper endorsements are in place. Based on the level you want to audit, the time spent auditing clients/files will vary make sure you allow enough time per CSR for initial review. Personal Lines accounts will generally take less time than Commercial Lines accounts. Audits that include Insurance auditing will take much longer than Audits that review only Data and Workflow Compliance. September,

7 Got Workflows? How to Audit for Compliance Use an audit form (and example is attached) so that you are always looking for the same criteria. A checklist provides a more objective review. Once the client/file audit is complete, the findings should be reviewed with the staff member and their manager. The staff member should have the opportunity to respond or make comments on those findings. Any corrective actions needed should be clearly outlined for both the specific client/file as well any other clients/files that staff member handles. If there any consequences of the audit findings, those should also be clearly outlined and both the staff member & their manager should sign off on those findings. Audits should become part of an employee s Performance Evaluation and should be reviewed at that employee s annual review to more objectively determine that employee s level of performance. After initial audit and findings relayed to CSR, audit again in 6 months to re-evaluate responsiveness to problem areas outlined in original findings. REMEMBER: Praise the good stuff you find!! Audits are a very daunting process to the employees involved. They need to know the things they are doing correctly. NOTE: If trends of non-compliance are discovered throughout all staff audited, those trends should be presented in a department meeting or some other form of communication to the staff involved so that necessary compliance is achieved throughout the agency. September,

8 Got Workflows? How to Audit for Compliance TAM Reports for Audit Purposes Auditing is a time consuming process. Utilizing reports to pull data from TAM can save you time and allow you to see trends in how your staff is handling customers, what type of service you are receiving from the insurance companies, etc. Activity Report Activities play an extremely important role in your agency s management of customers, employees, companies as well as prospects and marketing. Activity reports are important in the auditing process. They document the steps taken in the workflows being audited as well as document the timeliness of service within workflow guidelines to a customer when auditing specific customers. Being able to take the results of an Activity Report to Excel provides you a tool to look at timing, consistency and accuracy of the various activities entered in TAM. Used in Auditing a Specific Customer When setting the criteria in the report, select only that Customer code under Clients criteria (select Specific Values and enter the Client Code), under Date Selection, use Date Entered and limit your dates to the period of time you are auditing (minimum of 3 months). Do not limit the criteria to a particular operator or CSR as other users may have a role in support and service of a client and you will want to review how those actions are documented. For Output Detail, select Full Detail; you want to be able to review the actual data entered in the activity detail; does it meet your agency s requirements and standards? Change the output of this report to Excel as it allows you to sort, and filter the results to see exactly the information you are looking for in the timeframe you are auditing. Used in Auditing a Specific Workflow There are times, when you have found issues with non-compliance with a particular workflow while auditing a specific customer that would suggest an audit of that process for all customers is needed. You can audit a process by selecting only the activities that are used in that process and reviewing results for timing as well as accuracy and consistency in completion. This provides you the tool necessary to determine if a process needs to be changed or enforced, maybe a necessary step is not being documented This report will also allow you to identify the users that are having problems with compliance. September,

9 Got Workflows? How to Audit for Compliance Exceptions Report Most agencies run an Exceptions report as part of their Closeday process but do not necessarily do anything with the information. Exception Reports provide you information about what types of activities are not being followed up on in a timely manner and who is the offending user. Some activities are not as time sensitive as others BUT lack of timely followup (as determined by the default followup and action dates set by your agency for each activity code), can highlight those areas of workflow that need attention. Transactions / Production Report With either Search of Transactions or Production Report taken to Excel, you can search whatever date range of transactions you want to determine if correct transaction types, ICO and BCO as well as commission percentages are being utilized. You can determine trends in mistakes or misuse as well as pinpoint who may need follow-up training on transactions. Search Customers Policies Current / Applications Searching your databases is as close as you will come to being able to do a system wide audit as you can get. A Search of Policies Current allows you to review if correct policy types, departments, statuses, commission percentages, etc, are being utilized. Searches of Applications allow you to verify that all users are entering data on ACORD and Custom Dec applications per your standards. Are necessary fields being completed? September,

10 Got Workflows? How to Audit for Compliance Account File/System Audit SAMPLE Account Name: <Cust Number Here> <Customer Name Here> CSR: Producer: Reviewed on: Comments: <CSR Name Here> <Producer Name Here> <Audit Date Here> Signed off: <CSR Name Here>

11 Got Workflows? How to Audit for Compliance <Auditor Name Here> Active Polices: <Put Screen Print of Current Policy List Here> OPEN Activities as of <Put Screen Print of Open Activities Here> See attached for detail <Attach Activity Report for at least the past 9 months here> Criteria should be ALL activities (regardless of operator) for the audited account. If you choose not to audit claims at the same time, you could exclude those type of activities.

12 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here BILLING SCREENS: DATA INPUT AUDIT - Audit the following areas: Yes No 1. Policy type used 2. Status code 3. Policy number 4. CSR code 5. Department code 6. Use of notes (if applicable) 7. Pay mode and billing method 8. Effective and expiration dates 9. Issuing co/billing co. codes 10. Commission - flat or percentage 11. Producer code and commission APPLICATION / DECLARATION PAGE (for * see addendum): 1. Are application(s) or declaration page(s) behind appropriate billing screen? 2. Are all coverage lines represented with completed application(s), if available? 3. Named Insured complete? 4. All locations on property schedule and/or statement of values, if blanket limits? 5. All vehicles on vehicle schedule? 6. All drivers on drivers schedule? 7. All equipment on equipment schedules? 8. Limits/Deductibles/Class codes accurate? 9. All loss payees, mortgagees, additional insureds included on application? 10. All underwriting and general info complete? Yes No

13 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here APPLICATION / DECLARATION PAGE (for * see addendum): 11. Future application feature used? 12. Moving current application to history used? 13. History information credible? 14. Dec page, are they complete in current? 15. Dec page, are they complete in history? 16. Are applicable coverage endorsements reflected on application or dec page? 17. Was agency procedure regarding activity(s) followed during quote, proposal, binding and Issuance process? 18. Endorsements: a. Timely request to company? b. System update? c. Management of activity date? d. Timely processing upon receipt? e. Policy detail moved to history prior to change? f. Change request complete and accurate? g. If request done via memo, is policy detail in history prior to change? h. If request done via memo, has manual change been made to current application or dec page to reflect? 19. Binder/Certificates/Auto ID Cards: a. Timely issuance at request/renewal? b. Accuracy? c. Agency procedure format? d. Management of activity files? 20. Transaction(s): a. Timely entry? b. Accuracy? c. Agency procedure format? 21. Correspondence: a. Timely? b. Utilization of form letter, if applicable? c. Agency procedure format? d. Attached to Client/Policy file in history? Yes No

14 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here COMMENTS: CLIENT FILE SCREENS / INFORMATION 1. Client file code entered per agency standards? 2. Is the client name, address, etc. information correct and input per agency standards? 3. Is the heading input and correct? 4. Are the following fields completed per agency standards? a. CSR b. Agency c. Branch d. Code e. Producer f. Phone/Fax numbers g. Note h. Occupation j. Service Charge k. Statement 5. Are OPEN client activities created behind specific policy(s) and maintained according to agency standards? 6. Is NOTES field being used according to agency standards? 7. Are INFO screens completed according to agency standards both commercial and personnel, if applicable? 8. Are all policy(s) entered and maintained according to agency standards? a. Type (Including sub-sections if applicable) b. Policy number Yes No

15 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here c. Exp date d. Company codes (ICO/BCO) e. Producer code(s) f. Department code g. Billing mode h. Premium i. Status Yes No CLAIMS INPUT LOSS INFORMATION SCREEN: 1. Timely: a. Was the loss entered into the system on the same date we were notified? b. Was the loss reported to the company on the same date we were notified? 2. Is the description complete per agency standards? 3. If note screen utilized, complete and per agency standards? 4. Is the DOL correct? 5. Is the company claim number entered? 6. Is the adjustor's name, etc. entered? 7. If claim open, is reserve amount entered, if applicable? 8. If payments, are paid screens updated? 9. Were status follow-ups performed timely? 10. Was the Loss Notice complete and accurate? 11. Was the code field entered accurately per agency standards? 12. If claim closed, accurate per agency standards? 13. If subrogation action, were Activities created and managed per agency standards? Yes No COMMENTS:

16 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here ACTIVITY / TRANSACTIONAL FILING ACTIVITY CATEGORY(S): 1. Timely: was the activity created within agency standards? 2. Accuracy: was the activity created within agency standards? 3. Was description line used effectively and within agency standards? 4. If change request, was policy history created correctly? 5. If endorsement request done by MEMO, was policy history created correctly? 6. If change request section did not update app, did operator update record and manually create history correctly? 7. Does the hard file contain any system document that is not required to be in the hard file per agency standards? (i.e. Binder,Certificates, applications, letters, etc) 8. Does the electronic file reflect receipt of documents from outside sources that are defined by agency standards? 9. Are open and closed activities created and managed behind specific policy(s) where applicable? 10. Are activities updated and/or closed out within agency standards? Yes No COMMENTS:

17 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here CLIENT DETAIL SCREEN YES NO Is the screen complete Correct client numbering format Phone & fax numbers listed Client code correct Comments: BILLING SCREEN POLICY # YES NO Is the screen complete Policy status correct Policy dates correct Billing type correct Commission correct Company & Producer Premium correct Comments: BILLING SCREEN POLICY # YES NO Is the screen complete Policy status correct Policy dates correct Billing type correct Commission correct Company & Producer Premium correct Comments

18 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here BILLING SCREEN POLICY # YES NO Is the screen complete Policy status correct Policy dates correct Billing type correct Commission correct Company & Producer Premium correct Comments: BILLING SCREEN POLICY # YES NO Is the screen complete Policy status correct Policy dates correct Billing type correct Commission correct Company & Producer Premium correct Comments: BILLING SCREEN POLICY # YES NO Is the screen complete Policy status correct Policy dates correct Billing type correct Commission correct Company & Producer Premium correct Comments:

19 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here BILLING SCREEN POLICY # YES NO Is the screen complete Policy status correct Policy dates correct Billing type correct Commission correct Company & Producer Premium correct Comments: APPLICATION(S) POLICY # YES NO Are all billing screens present Are all applications present & complete Have future apps been deleted? Are previous apps in history? If missing or incorrect information list fields here: Shown On App Shown on Policy APPLICATION(S) POLICY # YES NO Are all billing screens present Are all applications present & complete Have future apps been deleted? Are previous apps in history? If missing or incorrect information list fields here:

20 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here APPLICATION(S) POLICY # YES NO Are all billing screens present Are all applications present & complete Have future apps been deleted? Are previous apps in history? If missing or incorrect information list fields here: APPLICATION(S) POLICY # YES NO Are all billing screens present Are all applications present & complete Have future apps been deleted? Are previous apps in history? If missing or incorrect information list fields here: APPLICATION(S) POLICY # YES NO Are all billing screens present Are all applications present & complete Have future apps been deleted? Are previous apps in history? If missing or incorrect information list fields here: ACTIVITY FILE YES # IF APPLICABLE NO Activity present for item processed Past due open items Open items over 30 days or critical Correct activity codes used Correct description entry Amount field used Comments:

21 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here MEMOS YES NO Title memos used Subject line complete Body of memo acceptable Should a document have been used instead of memo Comments: DOCUMENTS YES NO Formletters used Description in document list correct Description in document list match desc in activity Body of letter acceptable Should a memo have been used instead of doc Comments: Info screen present Screen complete Screen present for each individual Comments: INFO SCREEN YES NO Are notes being used Completed correctly Comments NOTES YES NO

22 Employee Name CSR Name Here Dept: Dept / Branch Info Here Date: Audit Date Here Account Name: Cust # & Name Here Claim detail screen complete ACORD loss notice attached to detail screen Claim notes used Claim payment record used Are closed claims listed as open Are all payments recorded Comments CLAIMS YES NO

23 Certificates Audit Matrix

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25 2009 TENCon Evaluation Kansas City, MO Thank you for attending this ASCnet session. By completing this evaluation, you will help us to identify what we did well and what we can do to improve the quality of our future sessions. Session Number: Presenter: Strongly Somewhat Neutral Somewhat Strongly Agree Agree Disagree Disagree 1. The learning objectives were met The session description was accurate The slides and/or audio-visual aids were of high quality The class materials/handouts were easy to understand and use The session was conducted in a professional manner The information was communicated effectively The presenter was knowledgeable about the subject The presenter created an enjoyable learning environment The presenter encouraged all to actively participate in the session The presenter effectively used examples to explain concepts The presenter effectively presented the material The presenter kept discussion on track The presenter allowed all participants to express their opinions The overall session was of value to me The time allotted to this session was appropriate How was the pace of the class? 1 Too Fast 2 Just Right 3 Too Slow 17. What would you consider to be the presenter s strong points? 18. Help me to help you what can we do to make this a better class? 19. What would you consider to be the STRONG points of this educational session? 20. What other topics would you like us to consider developing for future sessions?