Untangling Medical Facts in Claim Disputes: Viewpoint

For busy claims adjusters and administrators handling medical claims and disputes, efficiency is king, and every second is crucial when sifting through a log of documents to make sense of the relevant facts in their case.

Gathering the necessary documentation and building a case of pertinent facts to prove what happened can be a painstaking process due to the document-intensive nature of matters involving medical claims. Building a chronology of the facts and the evidence that supports them is the most effective strategy to paint a clear timeline of the case and help settle a dispute.

Building this kind of chronology can be done on traditional platforms like Word or Excel by listing each fact in chronological order alongside the name of the associated document and page number that proves the fact. However, this approach is fairly primitive, time consuming and creates challenges as the case progresses, which lead to inefficiencies and lost time – especially in more complex cases.

In a case of any complexity or in smaller cases where more efficiency is needed, it is better to use a solution that has relational database power and more dynamic capabilities to manage the facts as the matter progresses.

A relational database is a software solution created to manage cases more effectively by storing and organizing facts, claims, evidence and other data into tables, which are then linked to existing data based on defined relationships. These defined relationships allow the database to pull up a supporting piece of evidence for a claim instantaneously, just by clicking the pathway associated with the claim.

Relational databases relieve claims professionals of the time burden that typically accompanies fact documentation by automatically linking facts to their supporting documents and organizing based on different relationships, such as timing, claims supported, individuals involved and more. Software such as Word and Excel do not automatically provide the relative connections like a relational database, and the antiquated approach also slows down the integration of new facts in between the preexisting facts of the case by requiring professionals to manually insert new rows or paragraphs when new or changed evidence is introduced into the chronology.

Take as an example an employer instructing their employee to complete a task that ultimately resulted in the employee being injured. Email documentation or other evidence can be used to support that claim and would be associated with the date and time it occurred, contacts involved in the communication and other related issues in the case. While all of this connected information is handily accessible in the relational database, manual documentation in Word or Excel requires the claims professional to dig for a fact’s supporting documentation and draw relevant connections in some other way, which typically requires several reviews of the documents.

Relational databases have the capability of built-in advanced filter settings based on the relationship of information, which makes it easy and straightforward for claims professionals to quickly focus their review of the facts on similarly categorized information. For example, a claims manager may want to filter their view of the chronology to only include facts related to a particular issue in the matter (e.g. facts related to the issue of the employee’s reasoning for doing something that resulted in an injury).Input of case facts can also be done directly from case evidence for some databases, saving time on manually typing out the information needed. Because the documentary evidence is included in the database, a good solution can enable claims professionals to copy text directly from the documents to create new facts in the chronology, which can save significant administrative time and creates the direct link from evidence to facts.

In addition to simplifying the input process, these databases also make updating existing facts and documents easy since everything is automatically linked. For example, updating the name of an evidentiary document just requires one change to the filename for that update to be made automatically everywhere the document name appears throughout the database. With a manually written chronology, that change would need to be made manually wherever the document is cited.

Some software tools powered by relational databases also have native document review capabilities wherein the software generates reports, such as statements of fact, to provide summations of case data for mediators and other third-party participants.

Another advantage to a relational database is that many allow for the creation of templates to replicate case structures and help prevent claims professionals from having to reinvent the wheel for each claims dispute. This provides case workers or claims adjusters with a more standardized process to build their chronologies – saving a considerable amount of time when creating a new case.

While certain tech, coding and Microsoft wizards could build a relational database themselves, the majority of claims professionals will need to evaluate solutions that already exist and consider a number of factors to determine what is best for their organization and needs.

For starters, consider the collaborative v. non-collaborative abilities – is it a cloud-based platform shareable across users? While some solutions only allow for on-site storage, a cloud-based relational database provides viewing and editing access to individuals in separate locations so they can review the documents and make updates to the case simultaneously. This mobility certainly frees up claims professionals from having to be in the same room or manage the claims exclusively during regular business hours.

Of course, security is also paramount when dealing with the facts of any legal matter, especially when handling medical claims and documents. The sensitivity of the medical records involved in a case require the utmost security to ensure confidentiality. To ensure a cloud-based solution is secure, there are some important security features to consider, such as two-factor authentication, support of reliable infrastructure providers and security encryptions of all files.

Finally, adding any new technology will present potential onboarding challenges as professionals have varying levels of tech savviness. Consider the availability of customer support to address those challenges when they arise, but also review solutions with an eye towards how intuitive they are. The process of adding new information, from uploading the documents, to creating facts and reports, should be quick and easy.

Having a relational database can make a claims professional’s life easier by removing the headache of searching through mass amounts of documents to find evidence and allowing the facts to be linked to the evidentiary documents and relevant building blocks of the case. While one could create a relational database themselves, building the software and writing the code, etc., the time and brainpower required suggests everyone may be better off using one of the solutions already available on the market, taking care when choosing one that is the best fit for the cases they handle.