By Tate Rice, PT, DPT, MBA, Director of Product Management, Healthesystems
For claims organizations, it’s a perfect storm of factors: an aging claims workforce, a shortage of incoming new claims talent, and pandemic pressures that include disrupted recruitment and training opportunities, impacts on employee mental and physical wellness, and, for some organizations, the nuances of a remote work environment.
More than ever, we are hearing from industry partners and the market how they seek solutions that will create operational efficiencies for their workers’ compensation programs. Findings from Healthe’s 2022 Annual Workers’ Comp Industry Insights Survey Report point squarely at claims automation solutions as a top priority, with 48% of respondents selecting it as the most important technology over the next 3-5 years for the workers’ compensation industry. Here is the kicker: it was selected as the #1 most important technology not only by claims leadership, but by front-line claims professionals, too.
This signals that the people on the front line of claims management – the people juggling heavy caseloads, serving as the go-between for a multitude of stakeholders, and making complex medical decisions that impact an injured worker’s recovery – want support. And there are so many ways in which claims workflow automation can do this.
Augmentation of Claims Team Capabilities
When we talk about helping to streamline claims workflows through automation, it can cause a degree of discomfort by what it infers – that it can somehow diminish the role and autonomy of claims professionals. There are many aspects of claims management that are an art form, where human experience and judgment is a key ingredient for making the best decision for an individual claim, as well as ensuring that claims management isn’t reduced to a one-size-fits all approach. Intelligent claims automation doesn’t eliminate this, it enhances it.
As a Doctor of Physical Therapy, much of my career has been focused on understanding the anatomy and physiology of the human body and how to apply the right tools and techniques to help optimize its function. As a director of product management, I approach the design of claims automation solutions in much the same way. What are the tools we can bring forth to help claims professionals function at their most optimal levels? Where are the areas that need to be strengthened? And how do we know when to step in – not just to give a helping hand, but to give them the resources they need to help themselves?
Many workers’ compensation organizations today are seeking solutions that help them do more with less. And automation can support or reallocate tasks for claims professionals in the best possible way to help capacity-strapped claims teams, by reducing where it makes sense and supporting where these professionals provide their highest value.
This can mean reducing operational burden. Imagine being presented with the same, duplicate bill from the same, out-of-network entity a dozen times over. Now imagine that automation can reduce that instead to a single decision point so you never have to see it again. And multiply that by the number of duplicate bills that come through on 150 claims. That is time which can now be applied to meaningful work.
Couple this with clinical logic that helps detect complexity that may have been difficult or time-consuming to identify through a manual process, and right-time decision support that helps the adjuster address that complexity right within their workflow. Now we’re not only giving claims professionals time back in their day, we’re helping them further optimize that time.
Reduction in Injured Worker Exposure
At the end of this continuum is of course the injured worker. Automation and right-time clinical decision support can help drive evidence-based decisions that reduce their exposure to ineffective and inappropriate therapies.
This includes current prescription drug trends, such as the prescribing of high-cost dermatologicals in lieu of more cost-effective and clinically comparable counterparts. There are also tremendous opportunities among ancillary medical products and services, where experimental devices and therapies that lack supporting evidence can drive significant portions of medical spend when left unchecked.
We have seen great success in addressing inappropriate prescription activity in these areas through intervention programs, when these programs are well-utilized. The key is ensuring that they are utilized at the appropriate opportunities. Clinical rules-based logic can be applied to auto-intervene with inappropriate or abusive prescribing practices, or partial automation can be applied to highlight complex problems more quickly for the claims professional to then action.
It follows that the #2 medical program priority identified in our industry survey was aiding front-line claims decision support. And automation that simplifies or reduces complex or highly clinical decision-making can be especially valuable in supporting new claims staff where experience may be lacking, or in remote work environments where the claims adjuster may not have immediate access to internal resources such as seasoned colleagues. It can also bring a level of consistency in the management of a payer’s overall claim population, by helping to level the playing field across their claims teams, so to speak.
Whether supporting claims staff, increasing efficiencies, helping to reduce inappropriate utilization, or capturing additional cost savings that may be lost through traditional and more manual claims management processes – automation is an increasingly important tool in helping promote the health and optimal function of claims operations.
About Tate Rice
Tate Rice, PT, DPT, MBA is a Director of Product Management at Healthesystems, where he leverages his strategic clinical and operational expertise to drive the development of innovative products, programs and services. In addition to his extensive clinical experience in the physical therapy space, Dr. Rice holds more than 17 years of experience in project management and business development within the healthcare industry, with proven capabilities in managing the critical aspects of project delivery, including operation management and business process redesign. His strategic vision and ability to develop and market services have enhanced patient care, access and value while sustaining growth in a changing healthcare marketplace. Dr. Rice earned his Doctor of Physical Therapy at Temple University and his Master of Business Administration at the Drexel University LeBow College of Business, both located in Philadelphia.
Healthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, physical medicine, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while improving the quality of care for injured workers. To learn more about Healthesystems visit www.healthesystems.com.
Healthesystems is a WorkCompWire ad partner.
This is NOT a paid placement.