By Anthony Cuva, CIO of One Call Medical
Although claims frequency has slowed, severity and complexity of claims are on the rise. To help address this challenge, many claim organizations are now partnering with service providers in ancillary areas of the claims process—such as diagnostic testing, transportation, language services, and dental referral management.
Traditionally, the specialty referral process lacked a sophisticated IT infrastructure and automation tools. As a result, the process was hampered by inefficient and ineffective methods to submit and fulfill these requests. Referrals often resulted in claims leakage, meaning there were missed opportunities to leverage optimal savings and results.
In this article, we discuss how technology has streamlined the specialty referrals process to ensure prompt service, quality care, and immediate delivery of results:
An Adjusters’ Efficiency Toolkit. Claims adjusters handle anywhere from 130 to 250 claims at any given moment. Not only do adjusters have a heavy caseload, but according to a recent study by the Katie School of Insurance and Financial services, they also spend 40 percent of their time on administrative duties, which do not advance claims toward closure.
An efficiency toolkit essentially reduces the administrative burden on adjusters, allowing them to focus more time and attention on critical tasks, such as managing their claims diary, setting reserves, or performing the three points of contact.
This toolkit automates and streamlines workflow and ensures cost-containment strategies are consistently performed. For example, automatic routing of phone calls helps to ensure treating physicians and injured workers schedule diagnostic tests with quality, credentialed providers, while also reducing diagnostic costs.
EDI Integration. Today, electronic data interchange (EDI) enables organizations to seamlessly collect and exchange data. Although many organizations use EDI for mandatory reporting and compliance purposes, specialty service providers have gone a step further, utilizing EDI to facilitate a more electronic, connected infrastructure. For example, they can streamline workflow with claims examiners, nurse case managers, and providers. In addition, many have implemented integration servers—such as BizTalk—to connect people, systems, and data to enable even tighter communication and collaboration within the claims community.
Electronic Referrals. Enabling electronic submission of referrals for specialty services—such as diagnostic radiology, transportation or dental services—is a tangible example of how electronic processes help to streamline a specific piece of the claims process.
For example in diagnostic testing, OCM schedules more than 400,000 diagnostic tests annually. Over the years, OCM has continued to invest in the technology to handle this volume with maximum efficiency, and in order to identify, map, and profile the best providers in various regions.
Electronic processes facilitate consistent, systematic procedures. As a result, appointments are scheduled quickly; turnaround on medical reports is prompt; information for both the treating physician and injured worker is timely and accurate, and even billing is more streamlined. Process improvements are possible through significant and ongoing investments in IT infrastructure, which supports volume, service, and performance excellence.
In fact, a secure, web-based referral icon can be placed on an adjuster or nurse case manager’s desktop to ensure referrals are routed for proper management. Claims staff electronically receive medical reports, and throughout the process, they receive automated notifications via email, so they’re updated at each step.
Self-Service. Today, the demand for self-service has grown as advances in technology create more opportunities. However, it’s critically important to realize that poorly executed self-service options have the potential to increase costs and alienate customers. It’s not just about efficiency, but user empowerment through multiple service options. For example, consumers can visit a bank teller or use an ATM. At grocery stores, they can use self-checkout or a cashier.
When given the option, many consumers choose self-service for a variety of reasons, including greater convenience, faster service, and ease of use. Accessibility is another important factor, especially as online self-service capabilities are now available 24 hours a day, 7 days a week, expanding service beyond traditional business and call center hours.
Online Portals. Online portals create yet another avenue for connectivity and communication with adjusters, nurse case managers, and providers. With these electronic gateways, claims professionals can more easily submit, access, and exchange data. In addition, since portals are available 24/7, these parties have convenient on-demand access.
For example, OCM subsidiary STOPS uses portal technology to ensure drivers benefit from an ease-of-doing-business with the organization. Its propriety system profiles drivers according to performance and satisfaction ratings among clients. Drivers who have reached a “preferred” status can login to view transportation requests, select routes, set driving schedules, and approve billing to ensure a speedy turnaround on payment.
OCM also utilizes portal technology to communicate with diagnostic radiology providers, which reduces the number of calls an imaging center has to make to provider relations. Instead, offices can logon to view their calendar of referral activity and list of patients. They can use the portal to obtain authorizations, check the status of a bill, and perform dynamic credentialing, which means they can update equipment or licensing information online. In essence, portal technology reduces the administrative hassle for providers.
Electronic Delivery of Images. In workers’ compensation, diagnostic testing is the critical first step to appropriate, cost-effective treatment of injured workers. With “quality” test results delivered early in the claim’s lifecycle, organizations can reduce the likelihood that seemingly simple cases become chronic, long-term, and expensive.
However, when a claim requires an independent medical examination (IME), second opinion, or a review by a medical committee, electronic delivery of images helps to ensure prompt review and timely medical decisions.
OCM developed a sophisticated IT infrastructure to support timely electronic delivery of images. In this way, diagnostic scans can quickly reach the hands of reviewing parties. Since images are transmitted quickly, physicians can make diagnoses earlier, and treatment decisions for injured workers can be made sooner—positively impacting return-to-work results.
Analytics to Unleash the Power of Referral Data. Each specialty referral represents an opportunity to benefit from savings, quality, and service. Claims organizations must ensure steps are consistently followed to utilize quality providers each and every time. Overpayments for services and inefficiencies in the referral process—what the industry generally refers to as “leakage”—is a significant problem that leads to millions of dollars of waste.
Since many stakeholders are also involved in the referral process, there is an increased likelihood that leakage will occur. To address this challenge, claims organizations must work with a valued partner that has in-depth expertise in maximizing referral savings, while operating within state-mandated guidelines.
Some payers may not realize leakage problems exist. Organizations should check to see if their service providers have advanced analytics to perform a more in-depth review of referral activity. This can help organizations to identify referral patterns and problem areas where leakage commonly occurs. Service providers should offer technology-enabled “capture” strategies to prevent leakage and optimize savings.
The IT Horizon
It’s a mistake to assume workers’ compensation claims will always be managed the same way. Sure, the basic tenants—to quickly respond to workplace injuries with the best, most appropriate medical care at a reasonable cost, and to return employees back to work as soon as medically possible—remain the same, but with the integration of the latest technology tools, claims processing continues to evolve.
As we’ve discussed in this article, modern web-centric technologies have enabled claims professionals to reap the value of improved service, workflow, and collaboration, while also more consistently facilitating cost-containment and quality assurance at each step of the specialty referral process.
About Anthony Cuva
Anthony Cuva is the chief information officer at One Call Medical, Inc (OCM). He has over 35 years of experience as an IT strategist and has demonstrated an ability to implement solutions in diverse technical environments as well as a proven track record in IT organizational development. He has held many key IT leadership positions over the years and has continually delivered sophisticated products and services to a wide range of audiences and clients while providing cutting-edge technical support and guidance. At OCM, Cuva leads by implementing state-of-the-art technology across all business units and his vision for integrating IT operations and services has been instrumental to the continued success of the company. He can be reached at Anthony_Cuva (at) onecallmedical.com.
About One Call Medical, Inc.
As a leading provider of specialty services, One Call Medical, Inc. (OCM) has worked with many workers’ compensation payers, administrators, claims professionals, and medical providers to understand the challenges in the specialty referral process.
Today, OCM leads the industry in investing in technology to streamline critical touch points in the process, enabling it to provide more efficient, convenient, and valued-added referral management. Automation tools have made it easier to manage referrals, ensuring that claims professionals benefit from the best price, quality, and service – each and every time.
One Call Medical, Inc. (OCM) is the nation’s valued partner in delivering a suite of easy-to-use, efficient and cost-effective specialty services that help claim professionals achieve superior outcomes. OCM is committed to providing service excellence that optimizes each claim and has set the standard in innovation, quality, and dependability. When the management of every claim makes the difference to an organization’s bottom line, they turn to OCM to provide easy, fast, and effective solutions. Through OCM’s specialty diagnostic, transportation, translation, interpretation, and dental network services, our customers benefit from access to fully credentialed providers, prompt scheduling of services, and improved care. For additional information regarding One Call Medical, Inc., please visit www.onecallmedical.com.