If you keep up with industry news, it will come as no surprise that workers’ comp claim volumes continue to decrease. There are many suppositions about the root cause including enhanced safety programs or the introduction of automation to replace hazardous work. It’s likely a combination of multiple things driving the decrease. But regardless of why, we know that carriers and third-party administrators are looking for new ways to lower their cost per claim in this diminishing market.

It’s typical to simply focus on reducing costs by increasing claims examiners’ caseloads or other measures as a solution to the growing problem. Why not also look for a more efficient model that inserts clinical professionals into your claims operation and reallocate your claims examiners to management of more complex claims?

In this article, we’ll discuss the importance of rethinking processes around Med-Only claims as a potential solution.

The Claims Examiner Market

In a recent survey it is estimated that there are currently 125,000 claims professionals working across the U.S. This survey only considered claims examiners; not management, clerical or ancillary staff, or public adjusters. Here’s the breakdown:

  • Large insurers comprise 70% of the overall adjuster population having the greatest number of staff adjusters
  • Third-party adjusters account for 23% of the industry
  • Regional adjusting firms cover 7% of the remaining industry

 

In speaking to one of the largest global insurance brokers, the claims industry is not the same, intriguing job career that it was 30 years ago. Fewer and fewer graduates are interested in working for large insurance companies, spending their career trying to climb the corporate ladder. As a result, there is an ever-growing need to find new ways to manage and support claims.

Med-Only Claims Overview

Med-Only claims continue to burden carriers and third-party administrators, because in many claims’ operations, examiners are asked to handle these claims as part of their larger claims inventory. And because of the examiner’s priorities, these med-only claims get the least attention.

Med-Only claims are typically simple claims to manage, but they require a proper medical review to ensure any outliers get identified quickly so that the appropriate intervention can be initiated. The key to these claims is quick resolution to minimize the overall cost per claim.

Most insurers break claims into 3 distinct buckets:

Level 1 (Med-Only Simple)– Non-complex injuries and no or little lost time from work where no disability benefit is due. These are typically handled by entry level staff and are typically an approved payment of the medical benefits.

Level 2 (Med-Only Complex)– Still no lost time benefits due but more complex issues. Each insurer will have different triggers for escalation from Med-Only Simple to Med-Only Complex.  Some examples are a certain dollar amount of medical paid, litigation, or claim duration.

Level 3 (Lost Time)– Claimant is eligible for medical and lost time benefits due to severity of the injury.

Clinical Support Solution

Imagine having a team of highly educated, licensed clinicians available to help quickly review Med-Only claims and assist the claims examiner in getting this inventory of claims pushed through the process at a 30% faster rate?

Shearwater has developed a support solution that allows the claims examiners to focus on the critical Level 3 (Lost Time) claims, while also quickly processing Med-Only claims. This minimizes the time and energy required to process the claims and lowers the overall cost per claim.

We break the process into 2 distinct buckets:

  1. tasks that require or are best suited for a claims examiner, and
  2. tasks that are more efficiently handled by a clinical professional.

 

After your claims examiner completes the initial actions on the claim, Shearwater clinicians take over the day-to-day management. Tasks like reaching out to medical providers after every appointment to obtain current status, obtaining and summarizing medical records, and asking for Maximum Medical Improvement/Permanent & Stationary (MMI/P&S) at the appropriate time. These are all tasks best suited for a clinician to handle.

Reviewing and approving medical bills also fits perfectly into our clinicians’ skill set. Shearwater handles some of the administrative tasks that drain time from your claims examiners’ day such as timely filing of state documents and preparing a file for closure. Our clinicians stay in contact with your claims examiner on a regular basis and immediately raise any red flags as they are identified, so that your examiners are up to date on where the claim is at all times.

Med-Only Claims Support Model

We work with our clients to customize clinical claim support models that drive better efficiencies in the overall process and position your most valuable assets (your people) into roles that best fit their skill sets. Our support model is proven to help carriers and TPA’s lower their overall cost per claim.

If you’d like to hear how we can do this for you, please contact us!

Allan Schroeder
EVP