For years, claims adjusters in the workers' compensation industry have been bogged down with excessive paperwork, hours of manual data entry, fragmented communication among all parties involved in a claim and compliance with numerous state reporting laws and regulations.
Today, new technology is helping adjusters automate and streamline routine administrative tasks and labor-intensive manual functions, and is allowing them to focus their specialized resources where they're needed most.
"Claims adjusters may spend nearly half of their day focusing on routine administrative tasks that have little impact on the outcome of a claim," says Randy Wheeler, CEO of Valley Oak Systems Inc., a San Ramon, Calif.-based software solutions provider to the insurance industry. "Timeliness affects workers' comp claims like no other area of claims management. From the moment a claim comes in to the time all parties involved are coordinated and the claim is settled, it affects the claim's outcome. The quality of the claims process depends on individual stakeholders receiving the right information at the right time so they can operate as knowledge workers, not paper pushers," he stresses.
The automation of the claims-handling process, along with the use of specialized online tools, is optimizing efficiency, increasing cost savings and improving outcomes in the workers' comp arena.
"Software is now being tailored for each individual's role in managing the claim, with applications designed specific to the role of each user, including claims adjusters, case managers, nurses, doctors, etc.," says Kirk Sexton, chief information officer at Choice Medical Services LLC, a Tampa, Fla.-based specialty health-care management organization. "We're putting claims handlers, nurse case managers, medical-bill analysts and anyone else who is involved in managing the claim in the best position to capitalize on their knowledge and expertise, which allows us to focus on improving the quality of care and positive outcomes for the patient," he stresses.
"Traditionally, workers' comp claims processing relied heavily on the expertise of specific adjusters, who tended to focus largely on individual bills, rather than the entire claim," says Ken Hannigan, director of systems development at MedRisk Inc., based in King of Prussia, Pa., which provides specialty managed care services to the workers' comp industry. "Today, technologically advanced claims-management workflow tools can improve adjuster productivity and consistency in claims handling by automating routine processes and enabling replication of best practices."
MedRisk provides a Web-based, paperless, workers' comp claims-management system that allows adjusters to focus on the whole claim, rather than just looking at one bill at a time. Adjusters can even attach notes and additional information to a claim when appropriate.
"Many state jurisdictions require notes and other attachments in order to process a claim, and it's often difficult to get this information to the insurance carrier in a timely manner for processing," explains Hannigan. "Our software marries bills with related case notes, legal documents, lab results and other pertinent information so everything an adjuster needs to process a claim is at their fingertips."
Nurse case managers, special investigative units, medical providers, insurers and employers all have access to information they need to see regarding the claim, with built in security measures to determine who has access to that information.
"The Web-based system offers connectivity with multiple parties via a single data pipeline, which works with legacy systems so companies don't need to replace their old proprietary software," says Hannigan. "In addition, the program increases the number of documents that can be automatically routed through the system without adjuster intervention, allowing claims professionals to concentrate on more complex, red-flag claims, thus improving the quality of their output," he notes.
"Immediately aligning a claim with the appropriate resources optimizes claim outcomes," agrees Glen Pitruzzello, vice president, workers' compensation strategies and practices, at The Hartford in Hartford, Conn. The insurer currently uses a proprietary triage tool that uses a predictive model to identify the level of expertise required for a particular claim and routes it to the right team member from the start.
"We align each claim with a professional who has the appropriate claim expertise, making sure the claim gets to the right handler at the right time, which helps ensure the claimant gets the most appropriate medical care and positively affects return-to-work," says Pitruzzello.
Claims are reported through a centralized system, delivered to the appropriate claims-handling centers, and enhanced with information sent from employers, medical providers or the injured workers themselves. Case managers are collocated with claims handlers and notes can be shared electronically with additional stakeholders in the claim.
"We're using technology to create documentation that makes sharing of information easier and automating processes that don't require human intervention," says Pitruzzello. "As a result, we're seeing positive trends in outcomes data, employees are returning to work sooner, and we're achieving favorable medical cost trends by proactively managing claims upfront."
THE POWER OF THE NET
At Liberty Mutual in Boston, Internet technology is being leveraged through the use of an internal Web-based application that provides medical management resources for claim handlers and nurses. "Putting meaningful information into the appropriate person's hands at the appropriate time to help manage claims is extremely important in workers' compensation," says Mark Sidney, vice president and general claims manager, national market claims, for the insurer. "We're leveraging technology to centralize information and deal with specialty areas--getting claims into niche areas where claims handlers have specific expertise."
While Liberty does not currently use an external online system for processing claims, Sidney can appreciate the value of such an Internet solution. "The Web gives people more access to data and critical information at their fingertips," he says. "Online systems provide instantaneous communication in real time, which provides more access to greater information, faster."
Scott Schimke, executive director of risk management at the Golden State Risk Management Authority, which provides workers' comp coverage to 135 public agencies in the state of California, has witnessed the powers of the Internet firsthand. As a certified examiner and former claims adjuster, he has worked with numerous systems and solutions for handling workers' comp claims.
"The Web has allowed us to streamline our operations, providing instantaneous sharing of information and allowing claims examiners to better utilize their resources," says Schimke. Golden State has been using a browser-based claims management system, provided by Valley Oak Systems, since 1990. "The system allows our examiners to access claims data from various locations, share information with nurse case managers, medical providers, investigative services, defense attorneys and other parties that need to be involved on a particular claim, and has streamlined the entire claims management process."
In addition, Golden State uses the program to track where injuries are occurring in order to better identify where loss-control resources should be focused. "The ability to move data to key people quickly, identify where losses are occurring and get employees back to work, whenever possible, is one of the major benefits of this system," Schimke says. "Particularly in workers' comp, the timeliness of getting all players involved in the claim early on, sharing data faster in a more streamlined way, leads to faster resolution of claims and a greater chance to return employees to work. The Internet gives us the opportunity to focus our resources where they're needed most."
Steven Dorn, chief marketing officer of Visual Risk Solutions Inc., a Frank Gates company based in Dublin, Ohio, notes, "The Web is a great unifier and integrator of technology. It gives various systems the ability to talk in a standard format, and empowers the different disciplines required to service a claim to communicate instantly. In addition, more states now require some form of online reporting, as part of the push to drive the speed of claims settlements. By handling claims online, adjusters, nurses, case managers, employers, insurers, medical directors and field review units all have instant access to data and information to act on a claim immediately, greatly increasing efficiency and effectiveness."
Wheeler of Valley Oak Systems refers to the Internet as the "missing piece" of the claims management puzzle that can help organizations quickly respond to injuries and improve communication and collaboration between all parties involved in the workers' comp process.
"Internet technology helps claims professionals focus on high-priority tasks that directly affect costs and outcomes, and companies that utilize these solutions can achieve measurable results over time that justify their investment," says Wheeler. "The main advantage of the Internet is that it allows individuals to share information as it develops and access it anytime, from anywhere. In the workers' comp arena, the efficiencies technology can bring to the table must be balanced with appropriate human intervention. Web-based systems allow that to happen."
is a writer in Pennsylvania.
November 1, 2005
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