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Industry Insights

Five Tips for Managing the Exceptional Claim

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Good claims management is all about anticipating and avoiding the unexpected and managing the situation to a positive outcome. It's about recognizing the signs that a case may be morphing into a crisis, noticing the waves receding before the tsunami, observing the silence and realizing that a storm is brewing. It's about recognizing and managing the exception to the rule.

Consequently, for optimal claims and case management to occur, there must be a strategy in place to be on the lookout for the claims that are the outliers of workers compensation the situation that falls outside the norm and requires a type of management that is extraordinary. This level of management is seldom demanded from a claims management team and may require expert resources to avoid the claim from blowing up in terms of duration, costs and medical care.

Examples of exceptional claims include:

  • Injuries that are or may become catastrophic and long-term in nature.
  • Injured workers who have co-morbidities or other illnesses or physical conditions that existed prior to the injury.
  • Older workers whose injuries may be more complex and who are also more likely to have co-morbidities.
  • Injuries that are outside the usual types of claims seen.

If these unusual claims are not properly managed from the outset, the impact on patient care and on costs may be much greater than most companies realize.

The art of identifying these situations before they careen out of control and swiftly applying specialized claims management expertise to contain them, requires a solution that has not been seen before in workers compensation. This solution is now available due to three factors: the existence of best-in-class specialty networks; the development of advanced analytics to identify the best providers; and easy-to-use technology tools that streamline efficiencies and reduce friction in the system.

With these three elements in place in an integrated claims management program, managers can reduce the risk of the exceptional claim by realizing:

  • Predictability of expenses through total spend analysis, lowest unit costs, leakage capture and increased network penetration.
  • Consistency of care management through centralized management, consolidated reporting, and technical interfaces that improve efficiencies.
  • Continuity of care through the expertise of a best-in-class network, total support throughout the life of the claim, and service and product delivery to optimize care.

The Five Steps to Containing an Exceptional Claim

How does this new model work in the real world? Here's an example.

If a worker suffers a serious injury that may be catastrophic or long term in nature, follow these steps:

Ensure that the individuals care is managed by a physician who has a track record of producing optimal outcomes in workers compensation cases. Advanced analytics now enable payers to identify who these high performers are. Initial research shows that high performers produce outcomes at 20% to 40% lower cost than other providers.

Connect the claimant and the physician through a network of specialty providers and specialists so that all aspects of care are delivered by quality professionals.

Care management is essential from the first indication that a claim may be complex or catastrophic. Have an early warning system in place or an immediate notification program to connect with the specialists who can manage and treat the patient, as close to the first report of injury as possible. The partner that is brought in should have in-depth complex care expertise that includes experienced clinicians, equipment and device management, and integrating the transportation and translation services that a patient may need. This partner must have the experience and perspective to understand the long-term impact of each care decision, the relationship of the injury to any co-morbidities the patient may have, and the implication of lifestyle, home environment and family dynamics on the patients recovery. Instead of order takers, the clinical team functions as care coordinators and educators who look beyond cost savings today to a long-term view of the ultimate outcome and total cost.

With many catastrophic or complex cases, the clinical team must closely partner with equipment and medical device providers, so the right equipment is selected and delivered, functions as expected, and is with the claimant only as long as it is needed.

The partners selected should be vigilant and ensure the case does not go on auto-pilot. Management of the claim may be going well today, but as time goes on, the care team needs to be continually on top of the case evaluating, assessing, and intervening as needed to keep it on track and to bring in independent perspectives to challenge the status quo, to determine if services and equipment are no longer needed and if cost savings can be achieved by making changes.

With this game plan in place, the complex claim is managed with predictability, consistency, and the long-term continuity that delivers the best results for the life of the claim.

While this model will work to ensure outstanding outcomes for an exceptional claim, it will also pay dividends in better medical care, lower overall costs, and streamlined efficiencies for ALL claims, the exceptional and the routine.

Will Smith is president of One Call's Equipment + Devices and Home Health + Complex Care divisions.

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