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Similar to a triage nurse in an emergency room, claims professionals must evaluate the severity of each claim that comes their way and quickly identify the appropriate next step. The better the diagnostic tools they have and the more treatment options available, the more likely they will be able to provide the best treatment for each claim.

Most of us think of triage when we watch reruns of MASH or medical dramas such as ER where triage is the time-critical process of sorting (and essentially prioritizing) injured people based on their need for, or likely benefit from, immediate medical treatment. Successful outcomes depend on accurate and immediate assessments of patient injuries, reliable data and having the resources to ensure proper treatment.

The loss intake center becomes a property/casualty carrier's ER equivalent--it is where their insured comes seeking "immediate care" for losses incurred. In their role as triage nurse, the Customer Service Representative determines the presentation of symptoms--the who, what, when, where and why of the loss event and sets in motion the path the claim will take based upon these symptoms. It is at this stage that a determination is made whether the claim can be fast-tracked or whether it will require more in-depth attention.

Some ER patients don't require in-depth examinations or extensive tests to reach the correct diagnosis. A cut finger may just need disinfecting, a few stitches, a tetanus booster and a "symptoms to watch for" brochure. This sort of nominal treatment would not have to be performed by a surgeon as their extensive skill set is better applied to more critically injured patients.

Similarly, an auto roadside assistance claim, homeowner's glass claim, or a "one-shot" medical only workers' compensation claim should be relatively easy to identify during the triage process. The key is recognizing those claims for what they are (and what they are not) as early in the claims adjusting process as possible and immediately routing them to the most appropriate resources--generally a high volume/low complexity fast track claims handling unit.

Claims such as these have no need for--nor would they benefit from--the skills of highly experienced senior claims adjusters. The involvement of resources like those on such claims will not likely impact their outcomes, but will likely cause resource shortages on the more complex claims for which senior adjusting resources are necessary and appropriate. In an ER, such resource misallocation could have grave consequences for the health of the patient.

COMING TO A DECISION

When a diagnosis isn't as readily apparent as a cut finger, triage nurses or ER personnel need help in determining exactly what is causing the patient's symptoms, so diagnostic tests such as x-rays, CT scans, or lab work can be ordered and the data used to determine the most appropriate next steps.

The same holds true in the claims adjusting process. That is where an appraiser, inspector, coverage counsel or other expert resources can be brought in to help determine the best course of action for the "claims patient".

Whether you are ordering the most appropriate tests in a medical situation or bringing the best resource experts into your claims situation, the key at this stage is do so without wasting time or resources or increasing costs and to seamlessly integrate this step into your triage procedure.

Just like a sick patient, a claim rarely gets any healthier while lying on a gurney waiting for adjusting staff to complete its manual processes to engage the necessary diagnostic resources. An efficient, automated process, at this stage, results in timely, accurate and consistent data that contributes to overall good claims decision-making.

Emergency rooms rely on the most leading-edge technology to help them make their diagnoses; so too should claims departments. Modern, highly flexible, "single source of truth" claims applications are vital in seamlessly tracking and receiving input from expert claims resources.

As the test results come in, medical personnel may decide that the patient needs care that requires a hospital stay. Similarly, a claim may require a more extensive adjudicating process. Deciding to admit a patient to the hospital or to escalate a claim to more skilled or specialized adjusting resources requires careful assessment. In a hospital, there are multiple "inpatient" care units--surgical, cardiac, neurological, intensive care just to name a few.

Sending the patient to the wrong unit will delay their treatment and divert valuable resources to evaluate and reassign the patient; resulting in wasted time and money and perhaps even jeopardizing the health of the patient. This is where experience plays a critical role. Less experienced medical personnel can access large volumes of "past cases" that are well documented and offer an excellent resource to help them determine the most logical and medically appropriate next step, and admit the patient to the correct unit.

Claims adjusters are not always this fortunate and for most carriers the skill sets of the most experienced adjusters on their best days are difficult to tap. Carriers rely on supervisory review of individual claim files or scheduled claim review round tables to impart experience, knowledge and actions into an individual claim handling plan. This process can be slow and cumbersome with only a subset of claims selected for review.

Unfortunately, not all claims selected may benefit while those in most need of review may never make the subset. Unfortunately, the claims systems in place at most carriers do little to provide system-driven "experienced claims insight" which would benefit the entire adjusting team and book of claims.

CLAIMS DIAGNOSTICS

Just as with medical professionals, the ability for claims adjusters to access and assess what has happened in similar cases and what the resulting outcomes are can be invaluable. Both professions require insight to create the best results in the care and handling of their respective patients.

In claims, this insight comes from good claims information. Good claims information in turn comes from good data, collected consistently, accurately and in a timely manner.

A well designed modern claims system enables this type of quality data collection. The modern claim application also provides capabilities for "claims business intelligence" to provide the opportunity and execution of data element based claim handling business rules. These rules are applied across the carrier's book of claims to provide recommendations, alerts and specialized "claim type specific" task plans within the claims application.

Modern "data driven" claims applications also support predictive analytics and other leading edge claims analytics and action based tools that can create the right treatment plan for the claim as early on in the adjusting process as possible. They can also enable a constant sampling across the "life of the claim" to determine that the claim patient is still receiving the appropriate treatment plan for their current condition.

Complicating the entire claims triage process--and the claims adjusting process as a whole--is the morbid truth that up to 70 percent of current claims adjusters are approaching retirement. With an acute need to bring more talent into the profession, fewer younger people are coming aboard. Deloitte Consulting predicts a shortage of 84,000 adjusters by 2014.

Unless carriers can engage in "technologically enhanced claims triage" and use modern technologies to automate and support key claims functions, capture the expertise of their retiring workforce and best leverage their increasingly scarce resources, their claims operations will slow to a crawl. The impact of these slowed operations would likely result in rising claims costs and plummeting customer satisfaction; a ready made prescription for profitability disaster.

In order to improve claims outcomes, best serve claimants and reduce claim cycle times, claims professionals must carefully evaluate the severity of each claim that comes their way while quickly and consistently identifying the appropriate next step.

Better data and better tools will enable better decisions resulting in the best treatment for each claim and best service for each claimant. With an impending crisis in the availability of experienced claims adjusting talent, carriers might want to consider investing in technology supported triage sooner rather than later.

MIKE MAHONEY is product marketing manager at San Mateo, Calif.-based Guidewire Software, a provider of core solutions to the property/casualty insurance and workers' compensation market

September 1, 2008

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