28 | MAY 2018 | Claims Magazine | PropertyCasualty360.com
You wouldn’t write a paper by typing random keys on a keyboard, just like you wouldn’t build a home by throw- ing 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.
The role of integration
The claims process revolves around the claims system — and
there are many options to help enhance core-processing capa-
bilities 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 in-
tegrate 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.
MEDICAL CASE MANAGEMENT
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.
BY REBECCA MORGAN AND BILL MORGAN