By: Betsy Robinson, Senior Vice President,
Coventry Workers’ Comp Services
The average cost of both medical and lost time claims continues to escalate driving both payors and employers to focus in more detail on the relative return for specific administrative expenses along with the underlying factors contributing to higher overall costs. As this focus has intensified, it has become imperative for workers’ compensation organizations to have a clearly defined information framework that supports identification of highest risk claims and drives quantifiable aggregate outcomes.
Most organizations use data to answer two questions that might be expressed as, “What has happened?” and “What is happening right now?” To do this, they usually select tools that provide hindsight and insight, but seldom consider the missed opportunities that could arise from a framework that enables foresight.
Traditionally, employers and workers’ compensation claim payors have relied heavily upon individuals to recognize risk on a claim-by-claim basis as well as intervene appropriately. Adjusters, and at times nurse case managers, armed with clinical guidelines and burdened with heavy claim loads, may or may not see a problem or take action soon enough. And then of course the relative return for their actions depends largely upon their individual experience and core skill in the art of claim management.
But today the industry seems to be evolving rapidly toward a more scientific approach to risk identification in claim management.
The Science of Predicting Risk
Google ‘predictive modeling in workers’ compensation’ and you will find pages of content relating to the subject. There are various tools emerging from new and traditional suppliers that profess to convert data into information for claim organizations to consume. There are journals speaking to the need to isolate the drivers of claim risk, including those injured workers most likely to fail as well as providers most likely to drive up cost without a positive outcome for the injured worker or the employer.
Similarly innovative network suppliers have developed the artificial intelligence to carve out high performing networks of providers based on their consistently demonstrated positive clinical and claim outcomes. As in predictive modeling to identify risk, at the strategic core of an outcome-based provider network is the belief that past behaviors are the best predictors of future actions.
In all situations, the value of the data model to isolate and predict risk ties directly to the size of the data store and the analytic skill of the organization.
OK, so there’s risk… now what?
Although most companies recognize the value of data as a strategic asset, few have demonstrated an ability to manage or capitalize on cross-organizational data. As the volume of captured information continues to grow, the “data-as-an-asset” challenge comes with increased urgency to more efficiently move data into actionable information used throughout an organization and in the marketplace.
Outcome-focused claim management cannot be automated. There is not a smart tool available that can absolutely drive a claim from injury to closure. We still need to rely upon people despite the fact that levels of experience and innate skills may vary dramatically and challenge our ability to drive consistent results.
Organizations need to develop and train their front line staff in the art of best practices for clinical and claim management to level the playing field and fully deliver upon the value of early risk identification.
Best Practices….. The Art of Resolving Risk
Claim adjusters and nurse case managers need training and defined pathways to act on the specific type of risk that is presented to them. The organizations that win in this information loaded era will be those that can most effectively balance the science of risk modeling with the skillful art of good claim management resident in their individual and collective knowledge base.
About Betsy Robinson
Betsy Robinson, Senior Vice President, is responsible for overseeing the Coventry Workers’ Comp Services product development, marketing and information strategy efforts. She is accountable for setting strategic direction, driving business growth through an integrated clinical solution to the workers’ compensation market, including employers, third party administrators and insurance carriers.
Ms. Robinson began her employment with Intracorp in 1982 and held various positions at the company through 1992, including Case Manager, Account Manager and Product Manager. She subsequently held various senior level positions within the industry at Genex Services and Medecision prior to returning to Intracorp in 2000 where she served as the Vice President for Product, Marketing and Information Management until she came to Coventry in January, 2011.
Ms. Robinson received her undergraduate degree in Teaching from Temple University in Philadelphia, Pennsylvania and her Masters degree in Counseling from Villanova University.
Coventry Workers’ Comp Services, a division of Coventry Health Care, Inc. (NYSE: CVH), is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers and insureds as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.