Throughout insurance history, workers’ compensation claims teams have struggled to keep up with the relentless torrent of case data. Now there’s a better way.
After years of promise and hype, artificial intelligence (AI) is redefining how claims professionals interact with technology and their customers. Properly applied, AI is becoming a profound force for nurturing human compassion and is already helping leading insurers do business better.
By sifting through and analyzing massive volumes of unstructured information, like doctors’ notes within medical records or physical therapy narratives, AI uncovers and presents insights faster than is humanly possible.
Freed from administrative tedium, insurance professionals can focus their attention on addressing the needs of injured workers and their employers, with greater empathy and understanding.
Organization vs. prioritization
As AI solutions become increasingly common, it would be easy to assume that every AI unlocks information hidden in case files equally. Nothing could be further from the truth.
Many AI solutions can successfully organize structured and unstructured data, such as putting it into chronological order, eliminating duplicate information, tagging medical terms, presenting a treatment timeline, and highlighting any new data received.
However, this can be thought of like using AI for arranging your email inbox. Although you’ve significantly reduced the time required for organizing your emails, you don’t know which ones are the highest priorities to address. Nor do you understand why they’re a priority, what are the next best actions you can take, and why those actions make sense.
Claims Guidance to the rescue
Fortunately, there’s a new solution called Claims Guidance that does all of these things. Already the most quickly adopted claims software by disability carriers, Claims Guidance is now entering the WC market and will be showcased at the Workers’ Compensation Institute (WCI) 2024 Conference.
But what is Claims Guidance? That’s a good question. Picture receiving constant guidance for prioritizing claims, applying best practices, and taking suggested actions, all based on real-time analysis of continuous claims data feeds and your organization’s historical handling patterns. Already proven in the market at leading insurers, Claims Guidance improves injured worker recovery speed and outcomes, boosts claims resolution rates, and reduces adjuster and claims manager workloads.
In other words, Claims Guidance goes beyond automating the process of organizing structured and unstructured case data. What defines and separates Claims Guidance from similar-sounding tools is its focus on actionability and proactivity. It is:
1) Predictive: Claims Guidance uses AI to analyze massive pools of claims data to forecast claim trajectories. This includes considering the primary diagnosis as well as the impact of associated factors.
- Primary Diagnosis: After reviewing all information related to a case, running comparisons of data gathered from thousands of similar cases in an insurer’s internal files, and accessing anonymized 3rd-party data, the Claims Guidance AI predicts the course of the claim. This includes identifying medical-only claims that do not require additional intervention and automatically rounding them for low to no touch adjudication.From First Report of Injury (FROI) Claims Guidance can automatically assign a lost time claim to the adjuster with the best skills for that particular claim. It also directs that adjuster to a claims resolution strategy that will get the injured worker on the shortest path to recovery.
- Comorbidities: By analyzing hundreds of thousands of injured worker claims, our research shows that nearly two-thirds of injured workers have at least three diagnosed comorbidities hidden in unstructured data. Nearly half have seven or more. Further, common treatable comorbidities that go addressed can significantly increase claim durations.
- Psychosocial Factors: Recent studies have revealed that WC patients are generally younger and healthier than their non-W/C peers, but their outcomes were generally worse. This places greater importance on early identification of psychosocial factors, including cultural, social, environmental, and behavioral, to ensure they’re addressed adequately.
- Other Forces: The Claims Guidance AI also considers other impacts and historical trends on a claim’s trajectory, such as current, impending, or potential legal involvement.
2) Informative: With predictions, Claims Guidance determines and presents the next-best actions in-context of an injured worker’s unique situation. For example, if an injured worker has an untreated obesity comorbidity diagnosis, Claims Guidance can suggest the appropriate medical, pharmaceutical, or other interventions and suggests that the adjuster route the claim to a nurse, medical specialty, or rehabilitation service provider. By supplying an intuitive summary of the claim and drill-down capabilities, Claims Guidance empowers the assigned claims professional to focus on the highest-value interventions for that individual.
Claims guidance also provides extensive customizable reporting options targeted to the specific needs of claims professionals, claims managers, claims executives, and C-Suite leadership. For claims managers, this enables greater visibility and control over priorities and workloads.
3) Instantaneous: Claims Guidance continuously re-evaluates every claim file as it evolves, including assessing new external data that affects claim outcomes, such as the approval of a pharmaceutical treatment. Then, the software alerts claims professionals to critical developments and suggested strategies, along with any resulting trajectory changes. This includes identifying cases that are exhibiting potential issues for fast management intervention.
Freed from the traditional diary-based model, claims professionals can focus their time and expertise on the highest priority clinical interventions, build rapport with the injured worker, and focus on getting that worker back to work. This is proven to help resolve claims weeks or months sooner than with traditional claims handling.
4) Compliant: As Claims Guidance also tracks regulatory requirements in every geography and jurisdiction, it ensures that every recommended action includes a rationale that is compliant with every State’s handling requirements. The software also factors in operational requirements and rapidly adjusts recommended actions based on evolving circumstances, whether regulatory or operational.
5) Adaptable: A comprehensive Claims Guidance solution goes beyond the AI-powered software to include an in-house consulting and analytics team dedicated to each customer. The team provides strong change management and other services that are critical for ensuring claims organizations can maximize utilization of the solution, evolve it to drive real impact, and realize the full potential of Claims Guidance.
It is recommended that WC insurers seek a solution that includes this type of service, to ensure achieving adoption goals, by providing assistance with onboarding, training staff, and advancing an insurer’s Claims Guidance deployment throughout the duration of the partnership.
Better claims handling for improved quality of life
Whether you’re a claims manager seeking a better way of ensuring your adjusters are working on the right claim, at the right time, or a claims executive interested in better tools for leading, measuring, and delivering results, AI-powered Claims Guidance is more than just an upgrade to how you operate.
Claims Guidance is a new frontier, where technology and human expertise interact to create a smarter, faster, and more intuitive claims handling process. It provides a deep understanding of every claim in a claim block, auto-adjudicates when appropriate, and evaluates each case continuously to place the most actionable claims at the top. Further, Claims Guidance immediately identifies cases exhibiting potentially problematic trajectories to enable rapid intervention.
Overall, WC claims organizations gain the visibility, control, and peace of mind that ultimately helps team members improve the quality of life for injured workers.
To learn more about Claims Guidance, visit us at the WCI 2024 Conference, or contact us at EvolutionIQ.com.
Rooney Gleason is an insurance industry veteran with over 35 years experience. Prior to joining EvolutionIQ as Chief Insurance Officer, Rooney has served as a broker, an insuretech executive, and, most recently, as a senior executive at Argonaut Insurance Group, where he was President of the Grocery & Retail group. He holds an Economics and Management degree from Babson College. Connect with him on LinkedIn.