The workers' compensation marketplace is faced with unique and complex challenges when it comes to claim processing. Keeping up with regulatory requirements, CPT codes, and changing fee schedules can cause even the most experienced claim adjuster to become overwhelmed.

To further complicate matters, the workers' comp arena is no stranger to consolidation. In recent years, the marketplace has seen many mergers, including Coventry's acquisitions of Focus and First Health. Mergers, combined with rising medical costs, have led to an increased interest in specialty managed care companies. This creates mosaic-like workflows with multiple PPOs, specialty networks, and managed care companies each handling a piece of the workers' comp puzzle. For claim adjusters, this means increasingly complex vendor management responsibilities on top of existing challenges.

In addition to this list of moving parts and parties, insurance companies, third-party administrators (TPAs), and employers are dealing with antiquated legacy systems. Companies continue to rely on claim adjusters' manual assessments to accurately process claims and to compensate for the limitations of their current systems. This includes confirming the accuracy of CPT codes in relationship to the approved, compensable injury, adhering to the appropriate state regulations, and providing the correct documentation to each involved party. The result is a tedious, time-consuming process.

This complicated and archaic workflow is costly by design. A recent study by the Katie School of Insurance and Financial Services at Illinois State University found that more than 40 percent of claim handling process time is spent on basic administrative items that do not directly affect the quality or outcome of the claim. The study went on to conclude that claim costs could be reduced by as much as 15 percent if claim technology is employed.

Cost containment is on workers' comp insurers' and claim professionals' minds now more than ever with a slowing U.S. economy specifically affecting the workers' comp industry in a couple of key ways.

According to the National Council on Compensation Insurance's (NCCI) 2008 Workers' Comp Outlook, reduced wage levels from payroll cuts and layoffs will cause workers' compensation premiums to decrease. Secondly, NCCI's study says low investment yields, thanks to a stagnant stock market, indicate that combined ratios will need to be at or near historic lows for insurers to earn an adequate return on capital.

To make revenue matters worse, NCCI's findings also show that workers' comp medical costs continue to rise at or near double-digit rates. As these costs increase, states are forced to develop various cost containment tactics. Not surprisingly, technology is one way many companies -- both in workers' comp and in the P&C industry in general -- hope to reduce expenses. A 2008 claim officer study by professional services firm Towers Perrin found that increasing reliance on technology was the number three emerging issue in the P&C claim industry. Many leading carriers in the survey said they are looking at technology platforms as a way to improve operational efficiencies and lower costs.

Controlling costs isn't the only problem plaguing claim professionals in workers' comp and in the P&C industry. An intellectual property concern has appeared on the claim industry's horizon. In the article "The Shrinking Pool," which recently ran in the special joint supplement of Tech Decisions and Claims Magazines, the insurance industry can expect a deficit of 84,000 adjusters by 2014. This problem is being fueled by the large number of baby boomer adjusters who will reach their respective retirement ages at the same time, coupled with a dwindling supply of new talent. Additionally, the Towers Perrin study found that personnel issues -- specifically recruiting and retaining talent -- were the top priority for a staggering 82 percent of the businesses in the survey.

So what can claims organizations do to improve internal processes during a time of economic woe, rising medical costs, and a diminishing talent pool? The answer may be to invest in new technologies that allow claim professionals to gain access to recent advancements in workflow automation. Technology is ready, willing, and able to be the solution to both the intellectual property and cost pressures facing many companies. If your organization is considering investing in a claim technology platform, here are some important features to look for before you buy:

? Does the business rule engine include out-of-the-box, jurisdictionally complete workers' comp rule sets?

? Are those rules updated automatically to accommodate ever-changing regulatory environments?

? Does the solution offer rule customization as a service to accommodate internal workflow changes and any employer or vendor partner routing needs?

? Are the rules sophisticated enough to deliver true workflow automation?

? Are the rules exception-based, meaning they are able to flag claim anomalies for adjuster intervention, supplying the relevant decision aids and communication templates, while automatically adjudicating non-exception situations?

? Does the application provide enterprise level reporting for monitoring system, vendor and adjuster performance?

It is important to remember that, more than ever, technology is a friend -- not a foe -- in the claim administration process. True value-added technology systems free adjusters' schedules, so they may spend their time on claims where their expertise makes a difference in the quality of outcomes and leads to more competitive levels of service. Technological solutions do exist that can help companies improve efficiencies, reduce costs, and ultimately better serve their clients.

Special Reports /

The Future of Workers&#039; Comp Claim Adjudication

Related Stories

Recommended For You

The Future of Workers' Comp Claim Adjudication