As their role expands, today's risk managers are facing greater challenges than ever before. But one constant remains: the importance of getting claims paid -- and paid quickly without any hassle. This sometimes-frustrating process can be simplified, however, with the use of the latest claims technology.
The following eight tips will help guide modern risk managers and let them know not just what they should be looking for from their claims technologies, but what their selected claims business partners should be looking for as well.
1. Be Open and Modern
It is typical that all of your risk management tools will not exist within one "suite." It is also almost certain that the tools used by your claims handling partners will not be the exact same set of tools that you have in-house.
The applications you select and enforce with your external claims handling teams should be of an open, modern design to enable timely and accurate data flows, ease of integration with your risk management information system (RMIS) and "anytime/anywhere" access.
2. Create Insight
The modern risk manager needs a system that can recognize and deliver "what you need to see when you need to see it" exception reporting. Technology business partners should be able to offer a series of ready-made insight reports that deliver relevant information per your predetermined alert thresholds or upon demand.
Many vendors will also be able to offer information management consulting services (their own or via partnership) to help you develop the appropriate set of insight reports specific to your unique needs.
3. Provide Visibility
Insight must be able to drive action. Thus, your set of tools needs to provide drill-down capability into the actual claim incident -- or series of incidents -- that is triggering the "look at me!" exception. From the identified exceptions, you need an automated method to inquire further, request activity or deliver an automated claims status request.
4. Ensure the Ability to Audit
Any system you select must offer a detailed, specific, point-in-time and easy-to-understand mapping of financial transactions and key claim handling decision points -- the who, what, when, where and how much.
5. Deliver Analytic Capabilities
A key to overall successful risk management is to "understand the risk." This includes the risk your program has already experienced and other hidden risks. Claims data-based, predictive analytics can provide a series of insights to help minimize the financial impact and certain shocks that some claims situations can create.
Likewise, your claims business partners should be able to show you their set of predictive, analytic solutions to demonstrate so you know they are doing their all to handle claims on your behalf.
6. Ensure Transferability and Accountability
If you elect to self-administer, your claims system should be able to support seamless transfer among internal resources or to your claims handling business partners. The transfer of what started out as a simple claim and then became a more complex medical and lost-time case should not require a time-consuming, paper-based transfer of the claim file. When multiple resources are required to assist in handling the claim, the claims system should be able to easily track assignment to each role and associated actions.
7. Be Flexible
Obtaining the maximum benefit from your selected claims technologies requires that these offerings enable your ability to incorporate your own unique and specific business rules. The rules must be able to be applied throughout the program, claim or individual transaction levels.
8. Look Deeper
For the claims that you outsource, the tools your claims handling partners use will have a substantial impact on your risk program results. Any failure to use appropriate claims technologies creates the potential for liability, poor compensability decisions, incomplete investigative steps, missed recovery opportunities and "more than appropriate" medical bill reimbursements and claim settlement values. No risk manager wants to deal with any of these hassles.
Your claim handling partners should be able to demonstrate the value of a series of modern software applications, business practices and depth of business partners (such as an MCO, PPO or nurse case management) they use in the handling of all your claims to ensure what they are paying on your behalf is the right amount, on the right claim, at the right time, to the right person, for the right reason.
8 Keys to Claims Tech Success
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