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Claims professionals
in the workers’ compensation industry have seen their jobs become increasingly
more complex. One Call Medical, the national leader in diagnostic management,
recently hosted a series of focus groups with claims adjusters to identify
their work life “wish list.” The top three items on this collective list were:
1) education, 2) increased productivity, and 3) ongoing guidance to improve
results, particularly in regards to quality, costs, and outcomes. This bulletin
focuses on adjusters’ work-related challenges and the solutions available to
meet their needs.
Claims professionals in the workers’ compensation industry are
managing a larger number of open cases while faced with changes in legislation,
regulations and reductions in staff more than ever before. The sheer volume
of work has made it difficult for many 
adjusters to properly manage claims
for optimum efficiency, cost-containment, and outcomes.
To understand the scope and depth of their work-related challenges,
One Call Medical recently held several focus groups with claims adjusters,
which revealed the three things claims professionals want most in order to
perform their jobs more effectively:
- Teach Me. Most states require licensed certification
to practice, as well as a certain number of continuing education units (CEU)
each year to maintain this license. By designing or offering courses that
qualify for CEU credits, payers can provide their adjusters with more in-depth
expertise, while also helping them to achieve their state-mandated CEU requirements.
- Make Me More Efficient. Claims adjusters
typically handle anywhere from 150 and 250 claims at any given time. Unfortunately,
the claims management process has progressed very little over the years and
still requires tedious manual data entry, time-consuming administrative tasks,
and other labor-intensive processes. As a result, their second wish is to
streamline workflow in order to efficiently and effectively handle their
caseloads.
- Help Me Perform Better. Although the claims
profession continues to evolve, the core mission of the adjuster remains
the same: to control costs, ensure claimants receive quality medical care,
and return employees to work as soon as possible. To achieve these objectives,
adjusters want a more structured approach to help them understand and improve
their claims-management performance.
One Call Medical has identified the following key strategies,
tools, and solutions to help meet adjusters’ needs:
- Online Training and Education. Webinars and
other self-paced online learning modules will provide adjusters with specialized
knowledge and expertise, along with state certification-required CEUs. Online
training opportunities also allow payers and third party administrators (TPAs)
to reach a broad audience of claims adjusters in a very cost effective manner.
- Outsourced Services and Productivity Tools. By
outsourcing specialized services and utilizing web-based tools, adjusters
can move claims through the adjudication process with greater efficiency.
By handing off specialized functions, adjusters can focus their time on the
claims that most require their expert knowledge and personal oversight.
- Ongoing Consultation. An analytic and consultative
approach enables adjusters to improve their own claims-management performance.
Payers can expedite this process by helping adjusters identify and improve
the processes, procedures, and behaviors that will lead to measurable program
improvements, particularly in regards to quality, costs, and outcomes.
PART 2: Making Adjusters' Wish List Come True
Education, Productivity Tools and Guidance
The demand for qualified and experienced claims examiners is
greater than ever. One Call Medical is helping payers and third-party administrators
(TPAs) to satisfy adjusters’ top “three wishes” — for education, productivity
tools, and guidance — in order to attract and retain the industry’s most talented
claims professionals.
Wish #1: Training to Do My Job with More Knowledge
Due to the depth of knowledge that adjusters require, their number
one demand is for more training and education. Most states require licensed
certification to practice, as well as a certain number of continuing education
credits (CEU) each year to maintain this license. In addition, their jobs require
them to become knowledgeable about a number of complex topics, such as liability,
compensation, litigation, medical terminology, and loss-prevention strategies.
Many payers are now working with partners to design and deliver
educational material and training sessions that help claims adjusters develop
greater expertise on various aspects of claims management. By designing courses
that qualify for CEU credits, payers also help adjusters fulfill their continuing
education requirements.
A number of national payers have begun to leverage webinars and
other internet capabilities to train a large, geographically disperse staff
of adjusters. For example, they may post training materials and self-paced
learning modules on web portals, so adjusters can easily log on to access educational
information.
One Call Medical has partnered with national payers and TPAs
to deliver training sessions on the need for and benefits of diagnostic claims
management. Most recently, One Call Medical launched a series of webinars and
continuing education units (CEUs) that help the industry understand and address
complex diagnostic testing challenges. These training opportunities are now
available online through the new OCM University. To register and view a calendar of events, go our home page,
enter the OCM
Knowledge Center, and select Webinars/CEUs, or simply contact One Call
Medical at the information below.
Training enables adjusters to perform their jobs with more in-depth
expertise about today’s diagnostic challenges and available solutions, such
as using a network of qualified physicians and testing facilities that consistently
deliver medically useful reports.
Wish #2: Services and Tools to Do My Job with More Efficiency
In a typical claims department, adjusters may handle 150 to 250
claims at any given time. Many claim departments still use outdated manual
data entry and a paper-based workflow. Claims adjusters end up wasting a significant
amount of time on routine administrative tasks that have little impact on the
costs or outcome of a claim. As a result, their second wish is to utilize outsourced
services and productivity tools that enable them to streamline workflow and
more effectively handle their caseloads.
- Outsourcing Specialized Services. Payers
have segmented the claims process so various experts handle specialized tasks.
For example, by partnering with One Call Medical, payers and adjusters can
delegate their entire diagnostic referral process - they no longer have
to worry about identifying the provider, scheduling the appointment, or following
up on the report or bill. One Call Medical handles the whole process.
At the same time, adjusters can rest assured that One Call Medical is working
on behalf of injured workers as well. Experienced care coordinators assist
in selecting diagnostic providers conveniently located for patients, which
reduces the number of testing delays and appointment no-shows.
- Online Productivity Tools. With
a growing volume of claims, improved efficiency is more critical than ever.
Payers can provide adjusters with tools to automate and streamline routine
administrative tasks and labor-intensive manual functions, freeing them to
focus their attention where it’s needed most.
Tools such as web-based technology can make a major contribution to improved
adjuster productivity. One Call Medical provides adjusters with a complete
set of electronic capabilities that streamline the diagnostic referral process.
Its online “Customer Center” provides adjusters with 24-hour access to the
status of their diagnostic claims and easily retrievable medical report information
in a secure data environment. The company’s integrated e-Response solution
provides claims professionals efficient and effective electronic communications
detailing referral and appointment notifications as well as medical reports.
These web-based capabilities help adjusters move diagnostic claims through
the system with maximum workflow efficiency.
As an example, here’s how some of these functions work as a time-saving device.
An adjuster is automatically emailed appointment confirmation, re-scheduling
notification, and scheduling information. Following an injured employee’s
appointment, One Call Medical secures the medical report from the imaging
center and electronically distributes the report back to the adjuster via
e-Response. This not only reduces the time adjusters spend on administrative
work, it also gives them convenient online access to diagnostic claims information
whenever they need it.
Wish #3: Reducing Claims Leakage to Improve Quality, Costs, & Outcomes
The primary mission of claims professionals is to control costs, ensure claimants receive appropriate medical care, and facilitate optimal outcomes, such as early return-to-work. One of their biggest challenges is not being able to quantify claims leakage—namely the wasteful overpayments that leech funds from a payer’s bottom line. Since adjusters are held accountable for their claims-management performance, their third wish is for continual feedback and guidance in identifying specific areas of improvement.
Many payers are unaware of how much they spend on high-end radiology services, or what percentage of their claims are unmanaged. In some cases, the claims examiner or nurse case manager may schedule an MRI or CT directly with an imaging facility—missing the opportunity to leverage diagnostic network savings and management.
- To further reduce claims leakage, payers must educate claims adjusters, nurse case managers and treating physicians on the proper procedures to schedule diagnostic services for injured employees. Initial treating physicians often schedule exams directly with out-of-network providers; a contributing factor in leakage. Advanced communication tools now enable claims adjusters to automatically connect the physician with a diagnostic scheduling agent.
- Adjusters realize that by using a specialized preferred provider network for diagnostic services, injured employees are referred to only the best providers who can consistently deliver accurate test results and diagnoses and more effective treatment plans. When injured workers recover and return to work quickly and safely, these results are reflected in an adjuster’s overall job performance.
- Finally, sophisticated networks can also identify the 10 to 15 percent of services that have already been performed, but still qualify for discounts. This retrospective savings process minimizes losses by re-pricing bills and reconciling payments with providers who have agreed to participate.
With this valuable information, adjusters are empowered to consistently apply the processes, procedures, and behaviors that positively impact quality, costs, and outcomes.
A Partner Dedicated to Delivering Results
The demand for knowledgeable, experienced claims professionals has never been greater. The shortage of new adjusters entering the field may reach a crisis point in the near future. With this in mind, it’s imperative that payers take the necessary steps to make these “three wishes” a reality in order to attract and retain today’s top talent. By meeting these needs, adjusters will be better able to perform their jobs more effectively and experience greater career satisfaction.
One Call Medical is committed to providing its clients with measurable diagnostic improvements, as well as offering their claims management staff with the training, diagnostic services, web-based technology, and analytic consultation they require to achieve outstanding results. This level of partnership is unmatched in today’s marketplace, making One Call Medical the provider of choice in the diagnostic testing industry.