| How to Drive Better Outcomes | | | | they at odds? Adjusters and medical |
| If a member of executive management walked | | | | management must partner on claims to drive the |
| into your office today and asked if you are using | | | | best outcomes. Is your program designed to |
| your TPA (third-party administrator) as | | | | make that happen? b. Are you using the right |
| effectively as possible to reduce claim costs, | | | | medical management services, on the right claims, |
| would you be able to answer with an emphatic | | | | at the right time? This is one area where you |
| “YES?” You might answer in the | | | | want to avoid an “all or nothing” |
| affirmative, but would you be able to | | | | mentality. Using medical management on ALL |
| demonstrate it clearly? Even if this never | | | | claims is not the way to improve outcomes, nor |
| happens, why not ask yourself the very same | | | | is requiring the TPA to ask for authorization to |
| question? | | | | use medical management on any claim. For the |
| The claim management program you have in | | | | best results, claims should be triaged at intake, |
| place with your TPA must be dynamic, flexible | | | | and again at appropriate intervals, to make sure |
| and responsive to changing needs and trends. | | | | medical management is engaged as soon as |
| Gone are the days when “what worked last | | | | needed for exactly what is needed. c. Is the |
| year will certainly work now.” Claim costs | | | | TPA’s provider bill review program |
| are a significant item on the balance sheet, so an | | | | producing above average results? Is there |
| effective, state-of-the art claim management | | | | anything YOU can do to improve the results (for |
| program has never been more important. | | | | example, posting PPO physician panels in |
| (Resource: | | | | workplaces, where allowed)? Are you soft |
| To drive better outcomes, you must continually | | | | channeling injured employees to PPO physicians, |
| reassess, refine and monitor your program. | | | | where allowed?d. Are you using a Pharmacy |
| Focus your review on the following key areas: | | | | Benefit Manager (PBM) to reduce escalating |
| 1. Claims handling, from intake to settlement, | | | | pharmaceutical costs and utilization? The savings |
| and everything in between -a. Are you using | | | | potential is great and should not be |
| the TPA’s most efficient method to report | | | | overlooked. e. Also consider Physician Peer |
| claims, i.e. reporting via the Internet? Is the TPA | | | | Review (PPR) and Utilization Review (UR) services |
| planning any claim intake upgrades? Are Best | | | | to reduce costs. |
| Practices in place for claim intake and are they | | | | 4. Risk Management Information System |
| being met?b. Are claims consistently being | | | | (RMIS), including reports and |
| handled as aggressively as possible? Are your | | | | benchmarking studies –a. Are you making |
| account instructions facilitating the claim process, | | | | the best possible use of the TPA’s RMIS? |
| or hindering it? Are the appropriate resources | | | | Have you, and other team members, received |
| and services being used, i.e., investigation, | | | | hands-on training on all system features and |
| surveillance, medical directors, defense counsel, | | | | functionality? Are there any system |
| etc.? c. Is your TPA meeting all Best | | | | enhancements available that would be of benefit |
| Practices? Are there any elements in your | | | | to you? b. Have you automated the |
| program that make it harder for your TPA to | | | | distribution of reports to your divisions and |
| meet them? Some of the best intended custom | | | | locations? Are you using customizable data fields |
| processes actually have the opposite effect, | | | | that enable you to target loss control efforts? |
| resulting in delays and inefficiencies. Resource: | | | | Ask your TPA for examples of how client |
| FREE WC IQ Test: Service model, including | | | | “super users” leverage the power of the |
| staffing and caseloads - a. Does the structure | | | | system.c. Are you partnering with your TPA |
| of your program meet current needs? Does it | | | | on benchmarking your losses against their book of |
| make sense to consider designated, dedicated or | | | | business and externally, against industry peers? |
| regionalized staffing options? What are the pros | | | | (workersxzcompxzkit) |
| and cons? Ask the TPA for client service | | | | Reach out to your broker and industry peers |
| delivery success stories. b. Are the best | | | | for ideas on how to make your TPA claim |
| adjusters on your claims? Are caseloads | | | | management program as effective as it can be. |
| reasonable? Are the adjusters properly | | | | Also, ask your TPA if they have a client advisory |
| supervised (typical adjuster to supervisor ratio is | | | | group in which you can participate. Think about |
| 5 to 1)? Some TPA’s, for a slightly higher | | | | how good it will feel to answer “YES!” |
| per claim fee, will cap adjuster caseloads at a | | | | with no hesitation when executive management |
| lower number on your program.c. Does your | | | | asks if you are using your TPA as effectively as |
| TPA have adjusters who are highly experienced | | | | possible…and, it will feel even better when you |
| and technically superior in certain industries or on | | | | are able to demonstrate it! |
| certain types of complex claims? Can they be | | | | Do not use this information without independent |
| used on your claims, if appropriate? | | | | verification. All state laws vary. You should consult |
| 3. Medical management services, when and | | | | with your insurance broker about workers' comp |
| how -a. Is medical management integrated into | | | | issues. |
| your claims management program (sometimes | | | | ©2009 Amaxx Risk Solutions, Inc. All rights |
| referred to as a “clinical model”), or are | | | | reserved under International Copyright Law. |