By Pat Sullivan, Chairman & CEO, ClearPrice Networks
For most of you reading this article, the title above probably evokes a response that resembles “well duh” or perhaps a more expletive-laden version involving the fictional detective of yesteryear, Sherlock Holmes.
However, for workers’ compensation claims industry leaders and stakeholders, this seemingly ubiquitous vision of the role of technology in claims operations has been elusive in recent years.
The combination of industry consolidation in the workers’ compensation claims focused technology and services vendor segment and the lack of a healthy startup and/or early-stage company development environment has led to the lack of effective “choice” in many technology and service vendor categories like claims system platforms, bill review services, utilization review, specialty network programs, ancillary services, PBM and IME/Peer Review. This happens in different and often subtle ways depending on whether it involves technology solutions, service providers or access to general and/or specialty networks (you can read about some general examples further on in this article).
For claims leaders focused on improving patient outcomes, implementing operational efficiencies and driving down claims’ costs, this lack of flexibility or choice of vendor solutions should be at most unacceptable, and at least troubling. Your goals should not be mutually exclusive, unavailable or unachievable due to the decisions, limitations, priorities or business practices of the very technology or service organizations that were created to serve you. After all, didn’t they just tell you recently that they put your interests first as their client or “partner.”
Sounds provocative, doesn’t it? It is intended to be. After all, the workers’ compensation “cost containment” industry’s entrepreneurial roots date back to at least the late 70’s, with innovative ideas, vendors and solutions proliferating through the middle 1980’s and early 2000’s, when consolidation first started to emerge in our industry.
However, over the last 20 years this consolidation trend brought us to where we are today – many of the “middle market” or mid-size vendors offering technology solutions and insurance services have been consolidated into large organizations. Burdened with old technology, multiple overlapping platforms, disparate systems, and challenged with resource consuming integration efforts, many of these large organizations stopped innovating. They instead began rationalizing their existing capabilities and pivoted to intensive cross-selling of legacy products from a single source – a model that many payers were already questioning the value of. And, in more insidious ways, by effectively creating “closed” or restricted claims systems, bill processing or technology ecosystems, these large organizations also impaired new and innovative solutions from being implemented, thereby preventing and/or reducing competition.
On a practical level, these “strategic” decisions by large organizations can limit a claims payers’ options, choices and access to new and emerging innovative technology solutions or service offerings that may help a claims organization achieve their goals of improving patient outcomes, implementing operational efficiencies and driving down claims’ costs.
At this point you may be thinking, “Yes, but what should I do about it?”
For claims leaders, some of the answers are as follows:
- Explore the capabilities and get to know the leadership of the many new and emerging middle market vendors that are offering innovative programs, technology solutions and services including claims systems, bill review and utilization review solutions, managed physical therapy programs, ancillary focused specialty networks, PBM, IME, peer review and other clinical services. They will be far more eager, creative, transparent and flexible when it comes to helping you achieve your goals. They will also likely be less expensive while producing better or at least comparable results.
- Be clear and firm with your vendor partners that you expect their cooperation and support in your pursuit of your goals including but not limited to improving patient outcomes, implementing operational efficiencies and driving down claims’ costs.
- When exploring new options and solutions, look closely at your own historical data and validate the “headline” results you are provided by your existing vendor very carefully. As we all know, “the devil is in the details” and you will likely be surprised at what you will find if you analyze it carefully yourself.
- If a bill review, utilization review, claims system or other technology vendor says a certain program or service that you are exploring is “not available” or “not enabled” in their system, ask why and seek an honest answer. Then ask the vendor offering the unavailable program or service for the same honest answer and compare the two. I doubt they will be the same!
The bottom line is, follow your own data, metrics, internal analysis and good judgment when exploring new, innovative solutions. And if your existing vendors will not help you enable a new program, vote with your feet and find a new partner that will. There are plenty of good options out there, including some best-in-class choices, if you are willing to explore them. After all, an open and healthy ecosystem of competitive technology and service vendors is important, so you have options when others run into trouble.
About Pat Sullivan
Patrick J. (Pat) Sullivan is the Founder, Chairman and CEO of ClearPrice Networks, Inc. (CPN). Pat brings 30+ years of payer and provider experience in the healthcare management segment to CPN including workers’ compensation, commercial group health, healthcare provider programs and employee benefits. As a serial business builder, executive leader, consultant and Board member of both public and private companies, Pat has either led or has been a key part of the strategic growth and success of numerous small to middle market sized companies.
In addition to his role at CPN, Pat also serves on the Board of Medlogix, a private equity sponsored technology and clinical services provider of auto and medical claims management solutions.
You can learn more about Pat’s background by visiting his LinkedIn profile.
About ClearPrice Networks
ClearPrice Networks‘ mission is to drive efficiency, transparency and lower costs into the sourcing, provision, billing and reimbursement processes in the DME, prosthetics, orthotics, medical supplies and home care service line in the ancillary services segment of workers’ compensation and auto claims industry. By eliminating the legacy “rebilling” business model, CPN is able to drive excess cost out of the healthcare system, lower costs for payers, accelerate the delivery of equipment and services, expedite payment to CPN provider partners, and contribute to better patient outcomes.
ClearPrice Networks is a WorkCompWire ad partner.
This is NOT a paid placement.