Claims Analytics

All This Talk About Actionable Intelligence

The data we collect is more powerful than ever before, but we still need to learn how to leverage it into information that can be acted upon.
By: | April 8, 2015 • 5 min read

Everyone in our industry these days agrees that using data more effectively can assist us to obtain better claim outcomes.  When speaking recently with one of our industry veterans, David Smith, divisional VP and risk manager from Family Dollar, he told me, “These days it is all about the analytics.”

Steve Pratt, workers’ compensation director for Berkley Southeast Claims, a subsidiary of WR Berkley, also commented recently, “Analytics are critical to showing progress in a WC claims program. Optimal outcomes can be defined in a number of ways. I believe that outcome metrics need to be focused on how to reduce the claim life, how to help injured workers stay at work and how we can support a healthier injured worker population.”

But how do we transform these desires for relevant analytics into actionable intelligence? In other words: What data do we need? When is it most useful?

How can I integrate the vast stores of data I have in my claims system with all the data I get from bill review, utilization review, case management, pharmacy management, physical medicine management, DME & HHC management etc.?

As I looked back at an article I wrote in 2006, “Pushing a Revolutionary Agenda,” where I first discussed the idea that integrating medical and claim data could help you answer questions you might have about your claim outcomes, I quickly realized that we now have so much more data coming at us, knowing how and when to integrate the data could really be overwhelming.

Here it is, almost 10 years later, and although our technology and the data collected therein is greatly improved and much more powerful, we still need to learn how to leverage the data into “actionable intelligence.”

A few definitions of “actionable intelligence” will help us understand what I mean:

  • Actionable intelligence is information that can be acted upon, with the further implication that actions should be taken.
  • The key to using actionable intelligence is discovering elements within it that a business can exploit to enhance performance.
  • Actionable information is data you can look at and make process improvements based on what you are seeing.

In addition to being accurate, timely, comprehensive and predictive it needs to be analytical to stimulate the exploratory thinking and provide context to ensure strategic alignment and direction.

Let’s assume the action you want to take is to increase the value of your medical management services, i.e. reduce the medical, indemnity and expense spend through improvements in those services. I am certain you already receive some outcome reports from your medical management vendors, e.g. network penetration and savings from bill review and each of your network partners, number of approvals, negotiations and denials from your Utilization Review vendor, “savings” from case management and your pharmacy benefit manager, etc.

“Analytics are critical to showing progress in a WC claims program. …  I believe that outcome metrics need to be focused on how to reduce the claim life, how to help injured workers stay at work and how we can support a healthier injured worker population.” — Steve Pratt, workers’ compensation director for Berkley Southeast Claims

Yet, these reports do not really tell you if there is more that you or your partners could be doing, i.e. what actions you or your partners should be taking in order to achieve improvements in performance.

For example, you know that you were able to direct 65 percent of charges into your PT network, (which is good for the network given how they create revenue), but is it good for you? For example, does that piece of “data” (65 percent charge penetration) enable you to take action that improves claim performance or outcomes? I suppose you could take actions that drove more charges into the network; however, does charge penetration tell you if the outcomes of the claims that were in the network were better than those that were out of network? Do you have the “best” PT providers in your network?

You may have other questions such as:

  • Which doctors continuously treat within the treatment guidelines and have better outcomes (return to full functionality, lower overall claim cost or disability duration)?
  • Are my overall PPO outcomes better than my out-of-network outcomes?
  • Is my utilization review focused on those procedures that cost me the most in each jurisdiction?
  • Which medical procedures should I send to UR, i.e. are you spending resources/money on UR of procedures that are approved most of the time?
  • Which of my claims are potential “creeping catastrophics”? How can I identify them earlier?
  • Are adjusters overriding recommendations from your medical cost containment vendors negating the savings you might have had?

Your medical cost containment vendors can answer some of these questions using just their data and some analytical skills. However, as Ann Schnure, Macy’s VP, risk management, discovered, “true actionable intelligence requires integration of the vendor data (bill review encounter data, pharmacy date, case management data) with claim data.”

Macy’s has been able to leverage this integrated data to identify the medical providers who have had the best outcomes for Macy’s employees and, as Ann noted, “we are now narrowing our networks state by state to eliminate the providers who do not meet our best provider guidelines.”

This integration process also enabled Macy’s to identify the common triggers amongst their longer-term cases and build alerts early on in the claim to keep these claims from becoming the next $500K claim. Macy’s experience points out that our cost containment partners and we need to go through a “paradigm shift” and possibly a “resource shift” to identify and integrate the appropriate data.  We have to look at our data through a new lens, the actionable intelligence lens.

Vendor partners need to be told that delivering raw data is no longer good enough. They must take the time to work with us to integrate their data with claim data that can turn that data into information and actionable intelligence that can, in turn, cause actions that truly enhance performance and outcomes.

We need to be open to and capable of exporting claim data or importing all the vendor data so we can finally understand the “real” impact vendors are having on overall claim outcomes, what they and we can do to laser focus our resources and dollars on those areas where we are experiencing the most “pain.”

So develop your list of “real” questions for which you need actionable intelligence. Let’s stop accepting reports that tell us what our vendors want us to hear and demand actionable intelligence!

After all, as David Smith from Family Dollar said, “It’s all about the analytics.”

Maddy Bowling is a principal in Maddy Bowling Consulting, Inc., a WC consulting firm. Bowling has 35 years of broad-based executive management experience within operating, corporate and consulting environments. She can be reached at
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Workers' Comp Leadership

Want Better Outcomes? Use the Right Tools for the Job

Liberty Mutual's new medical director says experience plus the rights tools equal superior claims outcomes.
By: | March 27, 2015 • 4 min read
doctor tools

When Dr. William Gaines started his career, indemnity was “king.” But the emphasis in workers’ comp has changed in the decades since.

“It’s focusing on the right medical care at the right time for the right reasons,” Gaines said. That’s why having the proper resources to manage claims is essential.


“That has not changed one bit,” he said. “What has changed is we’re using much more sophisticated tools to guide these injured workers back to work.” Gaines is credited with helping to implement the following tools during his 12 years with Liberty Mutual:

  • Data analytics. The company says it was the first property/casualty insurer to use the “sophisticated data analysis long standard in the group medical industry” in the workers’ comp space, according to a statement.
  • Predictive models. Generated through the company’s data analytics capabilities, a variety of predictive models have been created that impact claims. For example, one “quickly identifies workers’ compensation claims likely to become more expensive than the average cost of similar claims. Claims managers are notified of these claims and the resources required to better manage them.”
  • Outcomes based networks. The company uses its data analytics to build networks of providers more likely to use evidence based medicine.
  • Prescription management. The company says its strategies helped reduce the amount it spends on narcotics by 13 percent last year.

As the newly appointed medical director of Liberty Mutual’s Commercial Insurance strategic business unit, Gaines sees himself as both a player and a coach. In addition to managing the company’s nine regional medical directors, he will continue many of the day-to-day functions he’s been doing in his 12 years with the company.

“I’ll be talking with providers, working with our nurses and claims managers,” Gaines said. “I have to be involved in working claims if I’m going to have the ability to work with medical directors and guide them.”


“When I talk about trends, [working] in the trenches and working with data, one thing that’s huge is the issue of … the inappropriate use of opioids in workers’ comp,” Gaines said. “There’s a lot more awareness on the part of treating providers in the workers’ comp system and employers that opioids have a very negative impact on injuries. But we have a lot more work to be done to develop a consistent basis and medical treatment guidelines.”


Gaines said getting the message to all providers is no easy task.

“Comp is a subset of group health,” he said. “We focus on group health and on workers’ comp with the hope that all of us drive provider awareness [to a] more conscious evidence-based prescribing of opioids.”

Gaines said identifying claims involving prescriptions from multiple physicians is a red flag. Working with pharmacy benefit managers is key to reining in opioid abuse.

“The only way you can manage opioids effectively is [by having just] one person prescribing them, confirming they are taken appropriately, and [that the opioids are] not creating adverse effects,” Gaines said. Having “multiple people is a prescription for failure.”

Psychosocial Issues

Another hurdle to achieving superior outcomes is psychosocial issues. “If you look at where problems occur in work injuries, the underpinning of why they don’t get better or return to work, it all revolves around an employee’s psychological makeup or social situation away from work,” Gaines said. “Not every injury is going to have the same response or outcome.”

Working in claims on a daily basis gives Gaines the opportunity to see differences in how injured workers are affected. One person with low back pain deals with it and doesn’t miss any work while another develops catastrophic thinking.

“Our challenge is to be able to recognize this early and intervene early with the right resources,” he said. “In the old days of comp, we talked about claims managers who could smell these early on. Now, with the complexity of workers’ comp issues, you just can’t rely on people to pick up on that.”

Gaines said that’s why Liberty has developed tracking tools — data analytics and predictive models — to enable claims managers and nurses and medical directors very early to identify if a claim is going off track.

Part of the answer lies in working directly with employers and helping them understand the importance of having supervisors communicate with employees. The insurer acts as a bridge between providers and employers.

“The way it is, there are a whole lot of providers that don’t understand occupational medicine is different from group health,” Gaines explained. Our “medical providers may be talking to the provider about things they are seeing and working with them, but at the same time, we may be talking with the employer to help them understand the person is still functionally able to come back to work.”


Predictive models supported by data analytics have been the single most important key to help spot a problem in a claim early on. While some of the more experienced claims managers can do that, newer ones typically cannot.

“It’s tragic if someone has a simple back strain and they never go back to work because we didn’t treat the psychological issues. You have to develop more of a specialty mindset. You can’t look at every claim the same way. You have to combine experience, data analytics, and predictive modeling.”

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at
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Sponsored: Berkshire Hathaway Specialty Insurance

Healthcare: The Hardest Job in Risk Management

Do you have the support needed to successfully navigate healthcare challenges?
By: | April 1, 2015 • 4 min read

BrandedContent_BHSIThe Affordable Care Act.

Large-scale consolidation.

Radically changing cost and reimbursement models.

Rapidly evolving service delivery approaches.

It is difficult to imagine an industry more complex and uncertain than healthcare. Providers are being forced to lower costs and improve efficiencies on a scale that is almost beyond imagination. At the same time, quality of care must remain high.

After all, this is more than just a business.

The pressure on risk managers, brokers and CFOs is intense. If navigating these challenges wasn’t stress inducing enough, these professionals also need to ensure continued profitability.

Leo Carroll, Senior Vice President, Healthcare Professional Liability, Berkshire Hathaway Specialty Insurance

Leo Carroll, Senior Vice President, Healthcare Professional Liability, Berkshire Hathaway Specialty Insurance

“Healthcare companies don’t hide the fact that they’re looking to reduce costs and improve efficiencies in practically every facet of their business. Insurance purchasing and financing are high on that list,” said Leo Carroll, who heads the healthcare professional liability underwriting unit for Berkshire Hathaway Specialty Insurance.

But it’s about a lot more than just price. The complexity of the healthcare system and unique footprint of each provider requires customized solutions that can reduce risk, minimize losses and improve efficiencies.

“Each provider is faced with a different set of challenges. Therefore, our approach is to carefully listen to the needs of each client and respond with a creative proposal that often requires great flexibility on the part of our team,” explained Carroll.

Creativity? Flexibility? Those are not terms often used to describe an insurance carrier. But BHSI Healthcare is a new type of insurer.

The Foundation: Financial Strength

BrandedContent_BHSIBerkshire Hathaway is synonymous with financial strength. Leveraging the company’s well-capitalized balance sheet provides BHSI with unmatched capabilities to take on substantial risks in a sustainable way.

For one, BHSI is the highest rated paper available to healthcare providers. Given the severity of risks faced by the industry, this is a very important attribute.

But BHSI operationalizes its balance sheet in many ways beyond just strong financial ratings.

For example, BHSI has never relied on reinsurance. Without the need to manage those relationships, BHSI is able to eliminate a significant amount of overhead. The result is an industry leading expense ratio and the ability to pass on savings to clients.

“The impact of operationalizing our balance sheet is remarkable. We don’t impose our business needs on our clients. Our financial strength provides us the freedom to genuinely listen to our clients and propose unique, creative solutions,” Carroll said.

Keeping Things Simple

BrandedContent_BHSIHealthcare professional liability policy language is often bloated and difficult to decipher. Insurers are attempting to tackle complex, evolving issues and account for a broad range of scenarios and contingencies. The result often confuses and contradicts.

Carroll said BHSI strives to be as simple and straightforward as possible with policy language across all lines of business. It comes down to making it easy and transparent to do business with BHSI.

“Our goal is to be as straightforward as we can and at the same time provide coverage that’s meaningful and addresses the exposures our customers need addressed,” Carroll said.

Claims: More Than an After Thought

Complex litigation is an unfortunate fact of life for large healthcare customers. Carroll, who began his insurance career in medical claims management, understands how important complex claims management is to the BHSI value proposition.

In fact, “claims management is so critical to customers, that BHSI Claims contributes to all aspects of its operations – from product development through risk analysis, servicing and claims resolution,” said Robert Romeo, head of Healthcare and Casualty Claims.

And as part of the focus on building long-term relationships, BHSI has made it a priority to introduce customers to the claims team as early as possible and before a claim is made on a policy.

“Being so closely aligned automatically delivers efficiency and simplicity in the way we work,” explained Carroll. “We have a common understanding of our forms, endorsements and coverage, so there is less opportunity for disagreement or misunderstanding between what our underwriters wrote and how our claims professionals interpret it.”

Responding To Ebola: Creativity + Flexibility

BrandedContent_BHSIThe recent Ebola outbreak provided a prime example of BHSI Healthcare’s customer-centric approach in action.

Almost immediately, many healthcare systems recognized the need to improve their infectious disease management protocols. The urgency intensified after several nurses who treated Ebola patients were themselves infected.

BHSI Healthcare was uniquely positioned to rapidly respond. Carroll and his team approached several of their clients who were widely recognized as the leading infectious disease management institutions. With the help of these institutions, BHSI was able to compile tools, checklists, libraries and other materials.

These best practices were immediately made available to all BHSI Healthcare clients who leveraged the information to improve their operations.

At the same time, healthcare providers were at risk of multiple exposures associated with the evolving Ebola situation. Carroll and his Healthcare team worked with clients from a professional liability and general liability perspective. Concurrently, other BHSI groups worked with the same clients on offerings for business interruption, disinfection and cleaning costs.

David Fields, Executive Vice President, Underwriting, Actuarial, Finance and Reinsurance

David Fields, Executive Vice President, Underwriting, Actuarial, Finance and Reinsurance, Berkshire Hathaway Specialty Insurance

Ever vigilant, the BHSI chief underwriting officer, David Fields, created a point of central command to monitor the situation, field client requests and execute the company’s response. The results were highly customized packages designed specifically for several clients. On some programs, net limits exceeded $100 million and covered many exposures underwritten by multiple BHSI groups.

“At the height of the outbreak, there was a lot of fear and panic in the healthcare industry. Our team responded not by pulling back but by leaning in. We demonstrated that we are risk seekers and as an organization we can deploy our substantial resources in times of crisis. The results were creative solutions and very substantial coverage options for our clients,” said Carroll.

It turns out that creativity and flexibly requires both significant financial resources and passionate professionals. That is why no other insurer can match Berkshire Hathaway Specialty Insurance.

To learn more about BHSI Healthcare, please visit

Berkshire Hathaway Specialty Insurance ( provides commercial property, casualty, healthcare professional liability, executive and professional lines, surety, travel, programs, and homeowners insurance. It underwrites on the paper of Berkshire Hathaway’s National Indemnity group of insurance companies, which hold financial strength ratings of A++ from AM Best and AA+ from Standard & Poor’s. Based in Boston, Berkshire Hathaway Specialty Insurance has regional underwriting offices in Atlanta, Boston, Chicago, Los Angeles, New York, San Francisco, Toronto, Hong Kong, Singapore and New Zealand. For more information, contact

The information contained herein is for general informational purposes only and does not constitute an offer to sell or a solicitation of an offer to buy any product or service. Any description set forth herein does not include all policy terms, conditions and exclusions. Please refer to the actual policy for complete details of coverage and exclusions.



This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Berkshire Hathaway Specialty Insurance. The editorial staff of Risk & Insurance had no role in its preparation.

Berkshire Hathaway Specialty Insurance ( provides commercial property, casualty, healthcare professional liability, executive and professional lines, surety, travel, programs, and homeowners insurance.
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