Like most insurance carriers writing workers' compensation, Capital City Insurance's Southeastern Claims Services used to deal with such massive stacks of paper medical bills that skilled adjusters were reduced to processing paperwork instead of using their expertise on complex claims.

In the past, Southeastern Claims sorted mail manually, sent bills to the medical bill review companies, received re-priced bills back from the medical bill review companies, and copied and circulated the medical notes and other required attachments proliferating in workers' compensation.

More often than not, copies of everything went to everyone working the claim, including case managers as well as adjusters. Frequently, bills arrived on the adjuster's desk with some piece of information missing, which meant they had to be rerouted internally and mailed back to the source with the accompanying request for clarification.

Increasingly complex workers' comp regulations -- different for each state and constantly changing -- meant that claim staff were required to adhere to even more special processing requirements and deadlines.

Naturally, each step bred additional clerical and administrative tasks, shifting adjuster resources, expertise, and energy away from the critical task of investigating and adjudicating complex claims.

For a technology solution, Southeastern Claims President Joseph Monteleone turned to MedRisk, a claim and medical management firm that offers workers' compensation claim management, workflow automation, and medical cost control services to insurance companies, third-party administrators, and state funds. A few years earlier, he had worked with MedRisk to help develop CLAIMExpert (privately branded as HealthPort), an ASP-based service to manage medical bills coming from thousands of providers and going to different staff and vendor partners for different purposes.

"Computers can simply do things people can't," Monteleone said. "Thirty years ago, we had names for injuries. Now there are numbers: CPT codes, provider IDs, diagnostic codes, all kinds of numbers. It's a lot easier -- and faster -- for software to match codes, injuries and body parts and scan for anomalies than for people to do it manually."

Now, Southeastern Claims' medical bills go directly to CLAIMExpert (HealthPort), where they are scanned, digitized, and indexed. Southeastern Claims' staff doesn't see an invoice until it is electronic and online.

Digitized claims move through a series of rules before advancing to the next steps, ensuring that all necessary data, like the provider number, is in place. These documents pass through some 10,000 rules. Screening verifies that the claim occurred within the policy period; that the procedure, diagnostic code and body part match; and that the bill is consistent with a workers' comp injury.

For example, a comp patient with a shoulder injury might also ask the physician to check out a case of tennis elbow while he is there. CLAIMExpert (HealthPort) would flag the tennis elbow as
non-compensable.

The system also attaches case notes, legal forms, lab results, and similar documents to the electronic file. CLAIMExpert (HealthPort) then sends the file to Southeastern Claims, where it appears in the claim professional's diary.

Targeted routing is another major time and cost saver. The system only routes files to the people who really need to see them. Case managers get only the files they need to address; adjusters get only the information that is required; and lawyers get the details that they need. Yet any authorized user who needs to see additional documentation associated with the claim can easily access that information without leaving their computer.

Work Queues and Decision Aids
Adjusters open their diaries to view bills, which are sorted chronologically. Then CLAIMExpert (HealthPort) coaches them through the decision-making process and automatically flags problems. The flag identifying what rule was violated appears in the file handler's diary. The file handler can accept, reject, or archive the flagged problem.

For example, a flag may indicate there are no medical notes, but if the notes came in separately, the handler would reject the flag and keep the claim moving. Or the file handler can generate a notice to the doctor that further information is required.

CLAIMExpert (HealthPort) also reduces the number of "touches" a bill receives. Extensive pre-screening rules identify incomplete data or inaccurate bills, automatically returning the document to the provider or vendor along with the appropriate documentation before it reaches the adjusters work queue. In the past, there may have been up to eight "touches" per bill, and now it is less than two. In fact, clean claims that pass all the rules get paid automatically without any human touch.

All documents transmit electronically, so there is no copying, collating, stuffing, and stamping envelopes -- and no time delays. Southeastern Claims' mailroom volume has been reduced by two-thirds, and the company requires much less paper, copiers, and file storage.

Claims that once required 30-45 days for payment are now paid within 10-14 days. Timely reimbursement has reduced the number of duplicate bills. Faster, more consistent and accurate decision-making has improved claim-handling outcomes. Before implementing CLAIMExpert (HealthPort), Southeastern Claims' managed care programs were saving an average of 38 percent per bill. This rose to 45 percent post implementation.

Just as important, adjusters are now doing what they are trained to do instead of wading through stacks of bills. "We need them to focus on the complex claims -- the ones that take research and investigation -- and now they have the time to do that," Monteleone said. "CLAIMExpert is a complete solution for dealing with workers' compensation medical bills that are all domiciled in one place, all available at our fingertips, and all Internet-based. It is a constantly evolving system that gets better all the time."

Special Reports /

Case Study: Returning Adjusters to Their Rightful Roles

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