Using technology to improve the claims process

When improving workers’ comp claims management through systems integration, companies must consider specific goals.

The key to successfully integrating new claims management systems is planning. (Photo: Shutterstock)

You wouldn’t write a paper by typing random keys on a keyboard, just like you wouldn’t build a home by throwing bricks in a pile. The keys to success in any significant and complicated project are forethought and planning.

The process of integrating the systems we use every day for claims processing is no different — in order to be successful, upfront planning is essential.

Due to the number of systems involved and their complex nature, system integrations can easily go wrong, leading to inefficient workers’ compensation claims management. For example, you may use a claims system as the core system of record for your claims handling as well as other expert systems for bill review, pharmacy benefits management, regulatory reporting, operational reporting, financials and more.

Have you ever thought about how those systems need to interact with each other to ensure proper handling of the claim? What would happen if the claims system did not communicate accurate and timely data to the bill review system or if the medical management team did not have insight into the pharmacy benefits management system? Would the injured worker receive proper care? Would those bills be paid properly?

Achieving a seamless and accurate claims process starts with a well-thought-out systems integration design plan.

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The role of integration

The claims process revolves around the claims system — and there are many options to help enhance core-processing capabilities by improving claims processes, reducing ownership costs and providing a better experience for claims stakeholders. The first step to successful integration is deciding exactly what to integrate with the claims system.

Here are some common areas that companies choose to integrate with the claims system to help improve outcomes:

Automating claims processing and fostering integrations with features already present on smart devices can help bring intake out of the realm of routine form filling and into more dynamic and meaningful interactions between the employer, injured worker and the insurance company.

Bill review relies on accurate claim data and claim history to make proper payment decisions. Optimizing straight-through processing workflows helps maximize efficiencies. However, it is just as important to notify the adjuster or bill review specialist when critical information on an invoice or request for treatment requires human intervention.

Case management relies on accurate data to make important decisions about direction of care and treatment plans. Integrations can bring richer medical data, worker status and other critical information to the adjuster’s attention.

Millennials aren’t the only ones pushing for a more customer-centric experience — this demand spans demographics. Omnichannel communications, not just traditional correspondence and forms, can help you reach a wider audience. A best of breed solution can help companies improve in this area. By expanding your capabilities, you can meet consumer expectations for more instantaneous communication.

Since the majority of states require electronic data interchange (EDI) for First Response of Injury (FROI) and Subsequent Response of Injury (SROI) reporting, most regional or national workers’ compensation insurers can benefit by having a third-party system to help manage reporting with automated workflows, edit notification and pre-built sequencing.

Analytic and reporting vendors that help manage claims with either real-time or historical reports and analytics are a growing segment of InsurTech.

Portals offer insureds, vendors, injured workers and other stakeholders a seamless way to interact with you, and meet expectations that have already been set by the likes of leading technology companies.

Since claims affect the bottom line, integrations can help an organization get a more robust and actionable picture of claim financials from executive to operational views.

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Design integrations for the future

In addition to standard integrations that many insurers and other payers typically perform, it is also important to consider future technologies when planning for integrations.

Consumer experiences are shaping the future of insurance technology — and many times, good consumer experiences boil down to excellent system integrations. Consumers expect to be able to engage virtually when conducting personal business with an organization. Why would claimants expect anything less?

Many individuals have an in-home smart speaker system or digital assistant. While it’s fun to ask these devices to tell a joke or say something funny, many people also use them for very useful tasks like turning off the lights in the garage. Why not use the same technology to report a claim? This is the reality of our future in insurance. To get there, we need to improve our system integrations.

For example, intake is evolving from more traditional forms like telephonic intake to new options like websites and mobile apps. Some insurers have innovated to gather photos or videos directly from a device and others have seen benefits in chatbots. There are many other opportunities for accelerating technology and smart devices in the claims process including accident pictures, live video intake and reflexive questioning.

All new technologies and innovations will need to take their place alongside the integrations we already know so well in workers’ comp, including EDI, bill review, document production and the like. New technologies remind us that integrations are essential not only in the intake phase, but throughout the claims process for both current and future systems.

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Best practices and planning

Setting expectations and executing proper preparations up front will make the integration process easier. First, make sure the organization is internally ready for the integration process. Here are a few steps organizations should go through to prepare:

After completing the value and resource assessment, evaluate what expert systems vendors can help improve the systems and processes. In the end, handling the due diligence and planning up front and then selecting a qualified partner to integrate with improves an organization’s chances for a successful integration that will improve their claims processes.

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Choosing the right partner

Just like in life, choosing the right partner is integral to the success of the integration. Here are some important characteristics to consider for the selection process.

Partner characteristics

It is also important to thoroughly evaluate the software system that will be integrated with the claims system. Here are a few areas to consider during this phase of the process:

Partner software characteristics

Creating a well-thought out plan and process for systems integration is just as important as creating a blue print when building a house. Defining what you want in advance, aligning key stakeholders and choosing the right partner will lead to a successful integration that can help organizations improve claim efficiency and overall outcomes.

Bill Morgan (BMorgan@guidewire.com) is a claims solution consultant with Guidewire Software. He provides critical industry knowledge to support Guidewire ClaimCenter’s Worker’s Compensation line of business and has served the insurance industry for over 25 years. Rebecca Morgan (Rebecca.Morgan@mitchell.com) is senior director of product management for Mitchell’s Workers’ Compensation Solutions. Her teams are responsible for both medical bill review and claims reporting software deliveries for the workers’ compensation market.

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