Maximizing Efficiency and Streamlining Claims Management Processes

In the fast-paced world of insurance and claims administration, the ability to efficiently manage claims is essential for organizations to provide timely and effective services to their clients. In the current digital age, various technological advancements help pave the way for transformative solutions in claims management. From automated workflows to data-driven decision-making, organizations have better access to the tools and systems that can help streamline their operations and drive efficiency.

In this course from PRIMA 2024, a panel of experts discussed the many strategies, techniques, and resources designed to help optimize claims management, reduce costs, and enhance outcomes. Learn innovative approaches for a more efficient claims management process, and discover the keys to better collaboration between injured workers, risk managers, healthcare providers, and claims professionals.

Featured speakers include:

• Alice Wells – Senior Vice President – WC/P&C TPA, Davies North America
• Silvia Sacalis – Vice President of Clinical Services, Healthesystems
• Greg Nichols – President, SPNet
• Emily Cameron – Director of Product, Gain Life

Optimizing Claims Management

Claims management is a very complex puzzle formed by three critical pieces: data, people, and technology. When claims are established, the goal is to ensure the best possible outcome for injured workers. In this process, early identification is critical, and leveraging the right tools can help eliminate monotonous work upfront, ultimately influencing the most reasonable solution. That is where Artificial Intelligence (AI) starts to fill in the gaps.

Today, AI is more prevalent for claims managers, healthcare providers, pharmacists, and anyone involved in claims processing. These highly intuitive computer systems are designed to help automate a faster workflow, along with a more efficient transfer of data. Channeling AI into your infrastructure is a great way to get ahead of the curve, especially when dealing with severe and complex claims. Essentially, automating a claims process can help drive a simplified analysis with predictive models and a holistic view of everything that the claim entails.

Claims Lifecycle

Administering a claim implies numerous opportunities, strategies, and impacts for various stakeholders. This process is structured around five critical stages:

1. Injury: The first step of a claim includes an initial report with details of the event linked to the injury (or injuries) in work-related settings.
2. Intake: A submission of the insurance claim occurs following the report of an injury.
3. Assessment and analysis: During this stage, all information is evaluated to help determine the extent of damages, loss, and risk severity.
4. Management: Once the investigation is complete, policies are reviewed, and proposals are developed.
5. Closure: An outcome has been issued and settled.

Pharmacy Management Continuum

The injured worker is the focal point of every case in workers’ compensation. It is imperative to engage the injured person at every stage of the claim. For pharmacists, experts assess necessary prescribe activity based on the injured claimant’s pain severity throughout the course of the claim. The scale measure includes three levels:

1. Acute pain: Pain lasting up to 4 weeks post-injury
2. Sub-acute pain: Pain lasting between 1-3 months
3. Chronic pain: Pain lasting more than 3 months

During this initiative, many other medical factors obtain focus, including a vast collection of patient data. Pharmacists take account for the injured worker’s medical history involving various applicable categories:

• Comorbidities and diabetes
• A change in pain quality
• Multiple prescribers
• Therapeutic duplication
• Suspected substance abuse
• Other use of medication
• History of depression
• Inconsistent UDS

Common AI Applications to Apply in the Insurance Process

AI is adaptive technology. It can help augment and streamline various claims capabilities. As AI programs rapidly evolve within medical management, stakeholders are tapping into its many functionalities. Essentially, AI is a partner in the claims process as it activates proper intel to help influence the best possible outcome.

Some of the key advantages automated through AI include:

• Summarization of the incident on the claim
• Sentiment analysis to help gauge structured data within the claims process
• Risk scoring measuring the impact and complexity levels regarding the injury/injuries
• Predictive evaluations of potential claims outcomes
• Recommendations with guided best practices for proposed actions

Social Determinants of Health

Injuries are not always caused by a single incident. The potential for injury can be affected by a series of health risks and societal influences, including:

• Access to quality education
• Access to quality healthcare
• Neighborhood and surrounding environments
• Social and community context
• Economic stability

Insights-Driven Engagement

Every claim starts with a specific point of data, but the injury is just one aspect to consider. While tracking a claim’s progression, it is vital to maintain oversight of medical providers and clinical efforts. Patient and stakeholder engagement should be regularly monitored at every level. By prioritizing technology solutions, users have access to an interactive dashboard to garner claims data, referral scripts, and insights regarding billing and ongoing treatments.

Improved Experience

The “new normal” has changed for the better. A more efficient approach to claims management is on the horizon, creating fresh innovations all around. Patients get a seamless tech-integrated experience with more informed care and data that helps match providers to corresponding injuries. Clients can expect more transparency on recovery drivers, real-time results, and optimized touchpoints of the claim. Adjusters and case managers streamline better communication, while providers leverage more synergy and gain access to clinically-driven results.