By Pat Chavanu, Senior VP, National Accounts and Marketing at GENEX Services, LLC
Last week, I shared news of Genex Services reaching a momentous milestone – 40 years serving the workers’ compensation industry. My last column reflected on key challenges that have occurred over those four decades which inspired the industry to evolve and adapt. This week I look at a specific area of advancement – the use of cutting-edge technology to both streamline and drive improvements in managed care.
Leveraging Sophisticated Technology in Medical Management
Clinical expertise is just one part of a three-pronged approach to meet the industry’s complex medical management needs. The second part is technology. Since we face constantly changing regulations at the state and federal level, agile technology is needed to ensure continued compliance and to automate regulatory requirements where possible.
In addition, modern IT platforms support and streamline clinical management to facilitate each customer’s unique workflow and processes, while also making use of business rules to drive a high level of automation across managed care operations.
Yet another way technology is improving claim outcomes is sophisticated case management applications that use diagnosis codes and other risk factors to score cases and identity those with the highest potential to experience a cost benefit from nurse involvement. These systems also incorporate tools that use information regarding comorbidities to categorize cases according to risk. The resulting severity scores help to focus clinical staff on the cases that would most benefit from oversight.
Using Data to Make a Difference in Claims Outcomes
The third component in a sophisticated managed care approach is a 360-degree data analysis. Predictive analytics can sift through millions of data points and forecast which claims are most likely to balloon into costlier cases or to result in poor outcomes – and the system proactively directs these cases for management. At the same time, machine learning – a form of artificial intelligence – is helping to analyze new streams of data to identify other indicators that a claim may be escalating. With these analytic capabilities, managed care companies can identify the claims that require more attention on both a macro and micro level, and they’re working with payers and employers to develop targeted strategies to address these concerns.
For example, a large, national company implemented early intervention using telephonic case management. The data from this initiative revealed the company could achieve greater value by implementing a nurse case manager specialized in medication issues to serve as a pharmacy champion. Today, this nurse serves as an extra set of clinical eyes to ensure medications are appropriate. In this way, the company can provide its employees with further safeguards against the dangers of opioids and other addictive medications while, at the same time, controlling pharmacy costs.
Technology has also enabled sharing data directly with injured workers. For example, we’re now seeing the use of text messages and push notifications used to transmit provider information directly to claimants’ cell phones. This accelerated movement of information can expedite the whole process and contribute to improved claims and RTW outcomes.
The Heart of the Matter
We’ve discussed many sophisticated tools, but we can’t rely on data alone. If there’s another key element to success, it’s passion. While some things have changed, others have stayed the same, and this is one of them – caring must be at the core of how we manage cases.
Throughout the industry, there are professionals with strong clinical backgrounds, and they must be provided with the tools to ensure evidence-based guidelines are applied. Equally important, these experts must be able to express empathy and compassion in their day-to-day interactions. It’s this “from the heart” approach that’s integral to the pursuit of managed care excellence. The cases that nurses work on are inspiring when we consider the resilience of injured workers to recover and reclaim their lives. But they’re able to do so because they have a compassionate advocate guiding them in their journey to get the care they need. And this heartfelt approach demonstrates that case managers aren’t just working to resolve claims, they’re dedicated every day to changing lives.
About Pat Chavanu
Pat Chavanu is a tenured leader in the workers’ compensation and managed care industry. As senior vice president of national accounts and marketing, he is responsible for creating detailed account strategies in alignment with corporate objectives, developing and refining programs to meet customers’ individual needs, and improve service and profitability across the continuum of care. Pat has held senior leadership positions with Genex for 15 years and also served as president and chief sales officer at other leading managed care organizations. Pat’s expertise is recognized by leading industry publications who often seek him as a source on topics ranging from workers’ compensation trends and business strategy.
About Genex Services, LLC
Genex Services is the trusted provider of managed care services enabling clients to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex is a managed care leader with more than 2,900 employees and 41 service locations throughout North America. The company serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems.
Genex is a WorkCompWire ad partner.
This is not a paid placement.