Viewpoint: The Power of an Optimized Workflow for Claims Adjusters

Claims automation can provide many benefits to the insurance industry. For example, implementing claims automation could free up54 million to 285 million adjuster hours annually, amounting to $1.7 billion to $8.9 billion in cost savings within five to seven years, according to Deloitte.

While automation can improve efficiency and lead to cost savings, it isn’t the only step to streamlining a claims workflow. Auto casualty and workers’ compensation claims can be complicated, often involving many steps and stakeholders. In order to achieve a fully optimized workflow, claims organizations should consider a variety of factors, starting with the three areas listed below.

The amount of time it takes for a claim to be triaged can have a lasting impact on the outcome of a claim. For example, the Insurance Information Institute found that faster triage at the first report of injury for workers’ compensation claims can reduce claim severity and lower the likelihood of litigation.

It is important that claim organizations triage claims not only quickly, but also to the right person or team that is prepared to handle the claim based on their expertise and workload. One way to help manage this is to specialize teams based on claim type, location or other factors. Traditionally, an adjuster could be assigned a low-dollar claim, a catastrophic case and a claim with attorney representation. With this type of varied caseload, it can make it difficult for adjusters to have deep knowledge in each area, therefore making it harder for adjusters to quickly come to the best decisions and recommendations for each claim. By specializing teams in specific areas, it not only lets adjusters become experts, but it also can help to triage the claim to the right team the first time — eliminating extra work down the line.

In addition to specializing adjuster teams, technology systems can also help assist in improving the triage process. Technology can help intake claims more efficiently, process the information needed to determine which adjuster or team to assign it to and automatically send it to that specified team.

Here are two questions that a claims organization can ask to improve the triage process:

• Is our triage process sufficiently automated to get claims to the right team as fast as possible?
• Are there any adjusters within our organization that we can specialize to a certain type of claim?

Bill review is a significant step in the claims lifecycle, so it’s important to consider improving bill review processes and automation when trying to optimize a claims organization’s workflow. At the heart of most bill review platforms is a business rules engine — an extremely powerful tool that can help a claims organization to boost efficiency, reduce the number of claim touchpoints and customize its workflow to meet its unique business goals. A rules engine facilitates claim automation, like auto-approving certain bills, so that your adjusters can focus on making important complex decisions. In order to achieve or maintain optimization, claims organizations should take another look at their business rules to evaluate if any can be updated to reduce claim touchpoints and improve efficiency.

Reducing claim touchpoints has a myriad of benefits and can help to optimize the claims workflow for improved outcomes. First and most obviously, automation assists in improving efficiency in the claims workflow, by allowing simple claims that meet pre-defined criteria to be automatically processed. Second, automation can help to improve consistency and accuracy throughout the claims organization. By removing the potential for human bias from simple and repetitive tasks, it’s more likely that similar claims will all be processed in the same way. Consistency and accuracy in claims evaluation results in more defensible and desirable outcomes. Third and finally, automation frees up time for adjusters to focus on complex decisions and problem solving in order for claims to have the best possible result.

The casualty claims process is complex, making it virtually impossible to automate the entire process for every single claim. While rules engine automation might not be the best approach for every task within the bill review process, claims organizations should be thinking through additional ways to implement automation in the best way possible to support its adjusters, and drive more consistent, improved claim outcomes.

Here are a few questions that a claims organization can ask when assessing their business rules:

• Are there any procedures that we can allow our bill review platform to automatically pass through every time?
• Are there any simple, repetitive tasks that our adjusters perform constantly that we could automate?
• Do we want to lower the threshold for auto adjudication to allow more bills to pass through without a human touch?

Another way for claims organizations to optimize their workflows is to leverage solution integration. There are so many different functions a claims organization needs to perform in order to effectively manage and process an auto casualty or workers’ compensation claim, between reviewing medical bills, performing utilization review or additional nurse review services, managing prescriptions and more. While there are a variety of great technology and service solutions available to help perform these operations, adding many disparate systems can make the claims workflow clunky.

Integration between systems can not only smooth out the process, but can also help to improve outcomes. Integrating solutions often means automatically passing data between systems, creating a more seamless experience and broader view of the claim for adjusters. For example, integrating a bill review platform with medical management software and having the data flow between systems can help to automatically enforce utilization review decisions, preventing leakage that could lead to overpayment.

Not only can integration help prevent data loss, but it can also help adjusters to make more informed and accurate decisions. For example, when pharmacy benefit management and bill review platforms are able to talk to each other, adjusters can better see what providers are doing in the office and connect that with what claimants are seeing in the pharmacy. This makes it easier for an adjuster to get a full picture of the claim without manually inputting data, and seeing this whole picture can help adjusters to make better decisions.

Here are questions that a claims organization can ask when assessing system integrations:

• Are there any tasks that adjusters perform in one system and then repeat or re-enter the data in another system?
• Are there additional integrations we can add to software solutions to provide adjusters with an even fuller picture of the claim?

Casualty claims are complex, and with constantly changing trends and regulations, claims organizations should be continually reviewing their workflows in order to achieve and maintain optimal outcomes. By improving triage processes, reviewing business rules and exploring solution integration, claims organizations can continue to fine tune their operations as they strive to provide the best possible outcomes for their clients.