The claims system is a tool that aids the claims staff to provide prompt and accurate delivery of benefits with a minimization of tasks and work hand-off. Systems are all much more complex today then they were just a few years ago due to rapidly changing business requirements and electronic reporting to the various state agencies.
Still, the key component of the system should remain the same: the ability to empower the user with the necessary information to make a quality decision in a timely manner.
It should also be a system that the user can easily learn, maintain and understand. This is in direct conflict with the need for greater system configurability, customization and functionality.
The claims administration system should be able to provide decision-making information to the end users of the data--anyone at anytime and anywhere (i.e., broker, insured, employees and management in other departments).
All that said, here are 15 guidelines for system development:
1. Focus on prompt, accurate benefits delivery to the injured worker.
2. Reduce or minimize the number of work tasks performed to close a file, including the number of times a person physically handles any paper and the number of handoffs from one person to another. It should encourage completion of each claims activity prior to handoff to the next expert or specialist.
3. Balance the need to gather information versus efficiency of claims handling. Gathering data (or additional input key strokes) may increase the number of tasks, but increase your ability to achieve a better outcome.
4. Keep in mind optimum claims outcomes by creating feedback loops and metrics to get the right information to the decision-maker. The system should be able to track objectives and performance standards where they have been quantified by the business, and have historical trending as well as a drilldown capability to isolate contributing factors as required.
5. Allow (encourage or mandate) compliance with all state and federal laws, rules and regulations.
6. Maximize client service. Client satisfaction here means a system able to generate client satisfaction surveys based on a pre-defined sampling method and questionnaire format. Results should be recorded in the system and incident/trending reports generated. An incident tracking mechanism should be in place where individual complaints and other customer service issues may be recorded, also with a report-generation capability.
7. Maximize client service. Allow direct access to appropriate status information for the injured worker, the employer, broker, underwriter, claims adjuster and company management (without betraying needed medical and operational confidentiality requirements).
8. Build or purchase the system in individual units or modules, each with the ability to be upgraded, or completely independently replaced, as technology, regulations and state environments change.
9. Cost-justify each unit.
10. Build each unit from the same technology base, capable of interface with no data integrity loss. Wherever possible, existing infrastructure investments should be leveraged to spare costs and to standardize options/practice enterprisewide. This may include: open source versus commercial applications and relational databases; Microsoft Office technology, calculator, thin client; analytics toolset and query tools; DATA Quality Scorecards; and cloud computing.
11. Maintain mission-critical processes or functions using the claims department personnel wherever possible.
12. Maintain ownership and/or lessee rights to program source code, wherever the company has created a unique business solution utilizing technology.
13. Allow for the setting of user preferences. Customization should allow for different options and looks/feels based on job duties, location and, in certain cases, individual ergonomics, as seen in portal websites.
14. Allow access to vital systems on a remote basis, preferably through an Internet/extranet connection (for instance, to download of investigation digital photo and video and subpoena records directly from the photo copy service).
15. Apply predictive technology to:
-- predict outcomes based on known facts and results.
-- identify critical claims path (with given claims facts, for each state and for each type of insurance).
-- triage claims.
-- predict ultimate claims costs.
-- predict medical outcomes.
-- identify best course of medical treatment.
-- identify fraud (provider fraud, employer fraud, claimant fraud).
-- predict partial disability percentage.
-- identify VR.
-- identify subrogation cases.
-- identify health and safety issues and predict future injury locations, times and positions.
-- predict litigation.
These 15 guidelines follow the 25 discussion points on claims systems I brought up in the first part of this column, published last month.
Though this advice is not conclusive, it should provide the starting point for any risk management or workers' comp professional considering his or her next claims system.
Ultimately, and put simply, an ideal system is modular based with simple, off-the-shelf customizable tools commonly available for a variety of platforms in technology that has demonstrated lasting power.
BILL ZACHRY is vice president of risk management at Safeway Inc., a Fortune 50 retail company, co-chair of the California Chamber of Commerce Amicus committee, board member of the California Self Insured Security Fund, and frequent workers' comp advocate in the halls of state and federal capitols.
(Editor's note: This column does not express the opinion of the State Fund or its board.)
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July 26, 2011
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