As hospitals and healthcare organizations work toward better patient care, they can begin by taking a closer look at their internal processes and technology. A reliance on disparate systems that fail to share data efficiently puts organizations at risk of falling short of the demands of modern healthcare. The Agency for Healthcare Research & Quality stated that one of the three most critical challenges facing today’s healthcare organizations in their mission to improve patient care is “establish[ing] an integrated data, analytics, and information platform, along with the necessary technical expertise, to capture a 360° view of the healthcare system.”
The healthcare claims process, too, can benefit from a single integrated healthcare risk management system. Having incident reporting and claims management functionalities working seamlessly in one platform offers three major advantages.
1. Increased efficiency and accuracy
Just as working with a single insurer is easier than working with several, integrating healthcare incident reporting and healthcare claims administration into one system can be easier than tracking each in separate systems. But unlike insurance, where receiving multiple coverages from the same insurer may not be possible, hospitals can integrate incident data and claim data with ease through healthcare risk management software like Origami Risk.
Having all data in one system adds convenience for healthcare risk managers who may have previously had to toggle between systems to follow along with the claim lifecycle—from the initial reporting of an incident to the closure of the claim. A daily reality that the article Improving Claims Management with Advanced Integration summarizes as “the need to switch between multiple software systems in order to find all the relevant information on a specific claim. It’s critical to have all pertinent data in one spot to reduce and/or eliminate this quest for data.”
Navigating between two systems also results in detrimental switch costs, the fractions of seconds that occur when moving back and forth between systems. These switch costs rapidly compound, leading to wasted time and increased errors, including misaligned data. With an integrated healthcare risk management system, healthcare risk managers no longer have to bounce between systems throughout the claim lifecycle. If an incident turns into a claim, they can monitor it or move it further along in the process without losing the original incident record.
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Greater efficiency in handling workers’ compensation claims can contribute to a reduction in claim costs and improved claim outcomes. These gains are quickly undone when errors result in penalties for the violation of state-specific workers’ compensation laws.
According to the article Avoid Workers’ Comp Penalties and Other Pitfalls, two of the five most common errors that result in penalties occur when filing First Report of Injury (FROI) and making mandated benefits payments to claimants. The use of workers’ compensation technology solutions can reduce the likelihood of making these errors, in addition to streamlining the claims process.
1. Simplify the process of completing First Report of Injury (FROI) forms
As mentioned in Improving adjuster efficiency and accuracy with an integrated forms solution, the process of locating a workers’ comp form and then keying claim details into form fields for every claim can be tremendously inefficient. This administrative burden reduces the time available for staff to engage in other activities that can have a positive effect on claim outcomes. This approach to populating forms also has the potential to add costs, including fines for late filing, errors, or the need to correct and resubmit forms.
The article states: “A reliance on manual data entry increases the likelihood of error and exposes the organization to the costs of bad data. In most cases, the work is also duplicative, with claimant and accident details having already been keyed into the claim system.”
The submission of inaccurate or incomplete claim details in the FROI can have consequences beyond the potential for incurring penalties. In the article First Report of Injury Accuracy Critical for Workers Comp Success, Rebecca Shafer, an expert in the field of workers’ compensation, points out that multiple parties typically use the information in the FROI when setting up their workers’ compensation files. As a result, even minor errors on the reports can be copied, creating complications down the road. And while these errors can be fixed by re-submitting a corrected form, Shafer writes that doing so “is a waste of time for all the parties involved. Plus, when the First Report of Injury is inaccurate or incomplete, it can often be exploited by the employee’s attorney.”
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An abundance of data accumulates in the claims management process. And while that data relays critical facts about each claim, that’s not the only insight it can provide. Data, no matter how seemingly unimportant, has the power to unleash valuable insight into your overall claims strategy. As the article Effective Data Discovery Can Be A Difference Maker For A Company’s Long-Term Success says, “Data that you may not even take into consideration can end up giving your company great insight after using proper analytics and data discovery techniques to make sense of it.” The failure to engage in data analytics means your organization may miss out on potentially rich data that sparks innovative strategy.
Benchmarking is one of the most powerful forms of data analytics. Used to measure competitor success and find areas for your organization to improve, benchmarking thrives on an abundance of data. With the right risk management information system (RMIS), you’ll not only be able to seamlessly collect troves of essential data, but also use benchmarking and other data analytics tools to extract meaning from it.
How does benchmarking make your data meaningful?
Data analytics can improve claim outcomes and, in some cases, help to prevent future claims by identifying trends and outliers that may otherwise go unnoticed. Benchmarking, specifically, involves comparing your data and performance against the industry’s best, which helps identify opportunities for improvement and establish long-term goals.
For example, risk managers, insurers, TPAs, and others who work with workers’ comp claims benefit from the annual Workers’ Compensation Benchmarking Study, conducted by Rising Medical Solutions. The study goes beyond merely reporting how claims payers are conducting business and outlines “how organizations turn the challenges identified in the prior studies into solutions and action.” The report’s mission is “to advance claims management in the industry by providing quantitative and qualitative research that identifies what high performing claims payers are doing differently than their peers.”
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A Risk & Insurance article recently stated that the souls of employees everywhere are saying, “Treat me like a human.” This applies to your claimants, as well. You’ve likely already considered many of the ways you can provide them better service, but you may have yet to tap into one of the keys to humanizing the claims process: automation.
The word is everywhere, as pervasive as the technology it’s infiltrating. Automation can bring to mind processes that are cold, robotic, and removed. So, considering software with automation functionalities may raise some hesitations. Will automation put distance between us and our clients? Will processes become mechanical and impersonal? How will this affect our service reputation and brand?
As the article Automation and AI: Miracle Tool or Hostile Takeover points out, automation “is neither the one answer nor a dangerous technology to be shunned. It’s another tool available to your organization, and every tool must be used effectively and for the right problem.”
Automation, when done properly, can bring more heart and soul into the work you do. Many manual processes consist of time-sucking drudgery. They leave you vulnerable to error and service headaches. They can become ingrained within your organization, forcing you to treat every claim or client the exact same way, despite variables, because deviating requires even more work. By using automation strategically, you’ll be able to deliver service to your claimants that’s more personal than ever. With a risk management information system (RMIS) that includes built-in automation, you can make humanizing the claims process a reality.
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Whether you’re an organization whose business is handling claims for others or one that administers its own claims, claimants are your customers. Viewing claimants through this lens will help focus your efforts on strengthening relationships and delivering better support. You also have the opportunity to go a step further and establish your reputation as truly customer-first. How? Through a straightforward branding exercise.
Before dismissing branding as something far removed from the claims world and better left to marketing and advertising executives, consider that every customer interaction further establishes an organization’s brand. Your reputation for customer service — however good or bad — is out there. You can continue with the status quo, or you can take control and push the narrative.
“Think about it,” says the Insurance Thought Leadership article 3.5 Ways to Deliver Happiness in Claims. “The claimant is going through your process during a time of grief, hardship and huge loss. Your process should not add to the stress. Your process should be easy. It should work to deliver a little happiness for them during this time. You want your beneficiaries to tell stories to their friends, family or other loved ones about how seamless your process was.”
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This post was originally published on Risk Management Monitor.
Regardless of whether or not their organizations operate in states where the use of Official Disability Guidelines (ODG) has been adopted/mandated, risk managers can often leverage ODG data and the claim data from their risk management information systems (RMIS) to benchmark the medical and lost-time components of their workers compensation costs against national averages.
With its origins dating to 1995, ODG (www.mcg.com/odg) provides “unbiased, evidence-based guidelines” and analytical tools designed to “improve and benchmark return-to-work performance, facilitate quality care while limiting inappropriate utilization, assess claim risk for interventional triage, and set reserves based on industry data.”
The following are some ways risk managers can use ODG data in conjunction with their existing risk information tools to drive improvements in their workers compensation case management and achieve greater precision in loss reserve practices.
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“A workers’ compensation adjuster is not a paper pusher.” That’s one of “60 Tips for Superior Claims Handling” issued as part of a panel discussion held at a past National Workers’ Compensation & Disability Conference. “Work comp claims are more difficult than general liability claims. If you think of them as a paper pusher, that’s the output you’ll receive.”
Numerous articles make clear the impact of adjusters’ experience, skills, and judgment on claims outcomes (For example, see “Good Adjusters Know When to Settle Your Workers Comp Claims.”) Nonetheless, as indicated by the fact that panelists felt it necessary to make the point that adjusters are far more than back-office clerks, the misperception persists.
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Searching for a critical email, multiple browser windows open, bills to review, reports to write, lawyer and medical professional consultations, voice messages that came in while on other calls. It’s all part of the daily routine for claims adjusters. Add outdated claims management software, disparate systems, and manual or paper-based processes to the mix and productivity can suffer. The work backs up. In some cases, the potential for burnout is all too real.
“Adjusters normally deal with a high volume of cases, and each case can be emotionally draining,” writes Katie Dwyer in the January 2018 Risk & Insurance article Improving the Claims Experience. “The customer on the other side is, after all, dealing with a loss and struggling to return to business as usual.”
“At some TPAs,” adds Dwyer, “adjuster turnover can exceed 25%.”
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Origami Risk’s 2018 User Conference, held last week, utilized a new format that not only placed a premium on client presentation of use cases, but also focused on digging into “how” presenters managed to implement their specific solutions. Listening to a diverse set of cases, several common trends emerged.
1. Transparency is key
Many of those presenting echoed the need to establish transparency and accountability in their processes. You can’t measure what you can’t see, and you can’t improve what you don’t measure. The most obvious culprits were paper-based procedures—everything from workplace safety “coaching cards,” to incident intake reports. Spreadsheet-centric workflows, such as data-heavy values collection efforts, also failed to identify the “who, what, when, and where” type of information required to make any process fully transparent.
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A good workers’ comp claim adjuster is a master of coordination. Managing 100-125 open claims certainly stands as proof. Yet, caseloads alone hardly tell the complete story.
For newly assigned claims, information must be collected from the employee, employer, and medical provider. Reserves must be established and reviewed for accuracy. There’s regular follow up with claimants, nurse case managers, attorneys, and other stakeholders. Compensability reviews. Evaluation of settlement opportunities. Mediations to attend. And that only begins to scratch the surface.
Yet according to the Accenture white paper “Claims at a Crossroads,” claims professionals can “spend nearly half their day on activities that do not impact the outcome of the claim.” While those administrative activities may be necessary components of the process, that time is better spent engaged in activities—such as those cited above—that fully leverage the adjuster’s talent and experience, keep claims moving on the path toward successful resolution, and increase the likelihood of outcomes that benefit both employee and employer.
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