How to Gather All Information Necessary for High Quality Claims Management

A significant improvement in the world of claims management over the years is the implementation of an electronic system for entering and managing claims. Used by employees of the Carrier/TPA, this is an automated system that assigns risk if certain conditions are present. These systems allow the claims professional to gather more information in less time, follow up appropriately on responses to high-gain questions, and evaluate the information systematically.

System Guides the Questions So Nothing is Missed

The person receiving the claim for the Carrier/TPA will have questions that need to be answered. If the answers are positive for certain criteria, the system will assign the claim a risk number within certain values from the software. The higher the score, the more risk is assigned to the claim. The system will be used initially for 3-point contacts to the injured worker, the employer, and the medical provider. Positive responses to certain criteria will pop up other questions to ask which ensures the adjuster does not forget anything that can be crucial to the claim.

When the claim arrives at the desk of the adjuster, they already have some risk areas highlighted that can negatively impact the claim. This streamlines investigation and saves costs as the sooner a problem area can be addressed, the better.

Adjusters are all under a heavy workload. Claims are in various stages of their lifespan, and some claims will get more attention than others. This program presents a way for new claims to get the needed attention they require as early as possible. Like any system, it also takes out a portion of the human factor. After a while adjusters can get stuck in a rut and a question could be missed or skipped by accident. The answer to that question could have a huge impact on the outcome of the claim. This system can prevent those misses, which helps everyone in the end. In no way does the system replace the need for a qualified adjuster, it does however, make every adjuster better.

Adjusters Can Receive Bonus for Following Best Practices

Bonus incentive can be another positive with the use of this program. Carriers/TPAs often use a bonus system to reward adjusters, and these bonuses revolve around timeliness of their contacts, resolution of their claims, and overall reserve savings by proactive claims handling. A system that helps the adjuster hone in on what gets them salary bonuses is a nice incentive to ensure they are motivated to follow best practices.

Makes Process Efficient

Claims can also be classified based on their system score. Medical only claims or minor lost time claims can be routed to the appropriate adjuster, instead of going initially to a senior level adjuster, only to be passed back to the medical only adjuster after contacts have been made. Many Carrier/TPAs will assign the claim based on what information is listed in the injury report. This process can be inefficient if the injury report was completed in error. Time and money can be saved when each adjuster is making the highest and best use of their day.

Outside Vendor Usage Identified Right Away

Outside vendor usage can also be identified right away. If the system has certain positives, it can trigger assignment to a field nurse case manager right away, instead of weeks after the claim process has begun. This is another proactive benefit as the earlier a claim can be assigned to a vendor for help the better. The outside case manager can get involved in the claim at the outset, instead of a month later. This can equate to large cost savings as this month can include crucial moves within the claim, preventing missed work when a return to work could have been possible. Another example is when the injured worker needs a medical referral to a specialist. Instead of waiting for the paperwork the case manager can get it at the appointment and send it to the adjuster the same day, instead of when the actual medical reports come in with the bill weeks later.

Summary

Several technological advancements are going on within the claim industry. As an employer, you should be open to new technology, and trying new things in order to be more proactive in the claim process. The same can be said for the adjuster. Oftentimes the adjuster is very set in their ways, and there can be some resistance to the introduction to new techniques and new technology. These advancements are made to help all parties involved to make the process more streamlined and more effective for the claims profession.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.

Contact: [email protected].

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.