Traditionally, the claims adjuster functions as the “traffic cop,” routing claims to the right department or expert, fulfilling requests for information, and ensuring tasks are performed in a timely manner. The new paradigm parallels this function, with the centralized claims hub acting as the “traffic control center” to manage workflow, optimize expert resources, and drive operational improvements. Instead of tying up valuable adjuster resources, the hub utilizes automation tools, such as automated forms, rules-based workflow, and diary systems, to fulfill routine and administrative tasks. This can save organizations as much as 20 percent in adjuster time and resources and allows adjusters to focus on the areas that directly impact the bottom line and achieve proactive claims management.

Improve Claim-Handling Quality

In the past, consistent claims handling was problematic; similar claims were often handled with widely divergent approaches and results. For example, in some complex injury cases, the same claim given to two different adjusters could produce a 100 percent variance in results.

Now, with workflow management integrated into the centralized claims hub, business rules and automated workflows are set up to ensure the application of consistent policies, procedures, and best practices throughout the claims organization. For instance, automated workflows can be configured to automatically route complex injury cases to adjusters with the appropriate level of experience in handling that particular type of claim. Business rules also trigger notifications to claims staff to perform specific actions, such as completing the three-points of contact and initial claims investigation within a certain number of days. Rules-based workflow ensures consistency and ultimately improves the cost and outcome of claims.

Enhance Communication

The number of litigated cases is on the rise, as well as the average amount of settlements. In states like Florida and Illinois, it is estimated that more than 50 percent of all indemnity claims are litigated. Lack of communication and coordination among claims staff and external stakeholders leads to significant losses and increases the chances that a claim will be litigated.

Through rules-based workflow, the hub prompts proactive communication and collaboration among stakeholders to reduce the likelihood of litigation. If injured workers stay at home for a prolonged period, they are more likely to obtain legal representation. However, if the injured worker has open and regular communication with adjusters and nurse case managers about the treatment and rehabilitation plan, expectations regarding a return-to-work date, and a modified duty assignment to accommodate the injury, the claimant is less likely to pursue litigation.

When a case must be litigated, Internet tools that are inherent to the hub, such as email and hyperlinks, help to share vital information between the adjusters and attorneys. For instance, a “guest” hyperlink sent via email allows a lawyer (or any other guest) to directly access claim information, connect to real-time notes, and update data directly into the claims system. The hyperlink is secure and access rights are easily defined and restricted.

Enrich Medical Management

In the past, efforts to include nurse case managers into the claims process have been inadequate compared to the dramatic benefits they can provide. Since the medical component of workers' comp claims now accounts for the largest cost increase in many jurisdictions, organizations have begun to focus on this factor in their workers' comp program.

By leveraging the claims hub, nurse case managers can fully collaborate toward quality care for injured workers. From the first report of injury, the hub immediately notifies nurse case managers of claims that need their involvement. The nurse case manager can then accompany the injured worker to the initial medical visit to obtain a proper diagnosis and treatment protocol from the physician, as well as guide the injured worker through the next steps to get them back to work. Nurse case managers have a critical role in communicating with the injured employee, ensuring that the employee complies with the course of treatment and understands return-to-work (RTW) expectations.

Develop an RTW Program

To facilitate optimal RTW results, nurse case managers must work closely with RTW coordinators. The hub automates the communication and collaboration between adjusters, nurse case managers, and RTW coordinators. A formalized RTW program can have a significant impact on claims costs and can help close workers' comp cases at least 50 percent faster than average claims.

Provide Enterprise-Level Analysis of Claims Experience

In the past, there was no effective way to look at the claims experience from an enterprise-level perspective. With the centralized hub, though, information resides in one location and is shared across all stakeholders. The resulting real-time business intelligence provides claims and risk management professionals with the data to monitor ongoing claim-handling performance and to design effective loss-control initiatives for high-cost and high-risk areas.

Empower Collaboration Toward Common Objectives

These examples of litigation management, medical management, and RTW coordination are just a few examples of how the centralized claims hub empowers stakeholders to proactively collaborate toward optimal claims results, allowing everyone to work toward a common set of objectives.

Hubs: Here to Stay!

The main goal of the workers' compensation claims process has always been to respond to workplace injuries with appropriate care at a reasonable cost, and to return employees back to work as soon as medically possible. As you can see, the infrastructure of the centralized claims hub allows organizations to drive operations with a greater ability to achieve these objectives.

Whereas traditional paper-based processes create inefficiencies and communication lags, today's claims hub is helping to revolutionize workers' comp programs, providing just the kind of coordination and management necessary to contain costs, improve outcomes, and achieve optimal RTW results.

Randy Wheeler is the Founder and CEO of Valley Oak Systems, Inc., a national provider of comprehensive claims administration and risk management systems, headquartered in San Ramon, California. For more information, visit www.valleyoak.com or e-mail [email protected].