If a member of executive management walked into your office today and asked if you are using your TPA as effectively as possible to reduce claim costs, would you be able to answer with an emphatic "YES?" You might answer in the affirmative, but would you be able to demonstrate it clearly? Even if this never happens, why not ask yourself the very same question? The claim management program you have in place with your TPA must be dynamic, flexible and responsive to changing needs and trends. Gone are the days when "what worked last year will certainly work now." Claim costs are a significant item on the balance sheet, so an effective, state-of-the art claim management program has never been more important. To drive better outcomes, you must continually reassess, refine and monitor your program. Focus your review on the following key areas: 1. Claims handling, from intake to settlement, and everything in between – a. Are you using the TPA's most efficient method to report claims, i.e. reporting via the Internet? Is the TPA planning any claim intake upgrades? Are Best Practices in place for claim intake and are they being met? b. Are claims consistently being handled as aggressively as possible? Are your account instructions facilitating the claim process, or hindering it? Are the appropriate resources and services being used, i.e., investigation, surveillance, medical directors, defense counsel, etc.? c. Is your TPA meeting all Best Practices? Are there any elements in your program that make it harder for your TPA to meet them? Some of the best intended custom processes actually have the opposite effect, resulting in delays and inefficiencies. 2. Service model, including staffing and caseloads – a. Does the structure of your program meet current needs? Does it make sense to consider designated, dedicated or regionalized staffing options? What are the pros and cons? Ask the TPA for client service delivery success stories. b. Are the best adjusters on your claims? Are caseloads reasonable? Are the adjusters properly supervised (typical adjuster to supervisor ratio is 5 to 1)? Some TPA's, for a slightly higher per claim fee, will cap adjuster caseloads at a lower number on your program. c. Does your TPA have adjusters who are highly experienced and technically superior in certain industries or on certain types of complex claims? Can they be used on your claims, if appropriate? 3. Medical management services, when and how – a. Is medical management integrated into your claims management program (sometimes referred to as a "clinical model"), or are they at odds? Adjusters and medical management must partner on claims to drive the best outcomes. Is your program designed to make that happen? b. Are you using the right medical management services, on the right claims, at the right time? This is one area where you want to avoid an "all or nothing" mentality. Using medical management on ALL claims is not the way to improve outcomes, nor is requiring the TPA to ask for authorization to use medical management on any claim. For the best results, claims should be triaged at intake, and again at appropriate intervals, to make sure medical management is engaged as soon as needed for exactly what is needed. c. Is the TPA's provider bill review program producing above average results? Is there anything YOU can do to improve the results (for example, posting PPO physician panels in workplaces, where allowed)? Are you soft channeling injured employees to PPO physicians, where allowed? d. Are you using a Pharmacy Benefit Manager (PBM) to reduce escalating pharmaceutical costs and utilization? The savings potential is great and should not be overlooked. e. Also consider Physician Peer Review (PPR) and Utilization Review (UR) services to reduce costs. 4. Risk Management Information System (RMIS), including reports and benchmarking studies – a. Are you making the best possible use of the TPA's RMIS? Have you, and other team members, received hands-on training on all system features and functionality? Are there any system enhancements available that would be of benefit to you? b. Have you automated the distribution of reports to your divisions and locations? Are you using customizable data fields that enable you to target loss control efforts? Ask your TPA for examples of how client "super users" leverage the power of the system. c. Are you partnering with your TPA on benchmarking your losses against their book of business and externally, against industry peers? (workersxzcompxzkit) Reach out to your broker and industry peers for ideas on how to make your TPA claim management program as effective as it can be. Also, ask your TPA if they have a client advisory group in which you can participate. Think about how good it will feel to answer "YES!" with no hesitation when executive management asks if you are using your TPA as effectively as possible…and, it will feel even better when you are able to demonstrate it! We are articles* on WC cost containment. Contact us at: Info@WorkersCompKit.com.
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