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Risk Insider: Rachel Fikes

3 Critical Steps Claims Organizations Need to Take Now

By: | June 1, 2018 • 2 min read
Rachel Fikes is Vice President and Program Director of Rising Medical Solutions’ annual Workers’ Compensation Benchmarking Study. Under Rachel’s leadership, the study is the industry’s largest survey of claims leaders and validates how high performing claims organizations differ from the average. She can be reached at [email protected]

In the past five years, I’ve learned a lot from the 1,700-plus claims leaders who’ve participated in our annual Workers’ Compensation Benchmarking Study. Now the study team has distilled five years’ worth of study reports into the top three distinguishing characteristics of successful claims organizations. Adopting these traits is critical for closing the claims performance gap — or organizations risk falling further behind.

Study results indicate 24 percent of claims payers are “high performers.”
How do the other 76 percent catch up?

  1. Best performers focus more on what’s most important.

Study participants define an employee’s return to the same or better pre-injury functional capabilities as the number one classification of a “good claims outcome.”  They also consistently rank medical management, disability/return-to-work management, and compensability investigations as the top three core competencies most vital to successful claim outcomes.

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But high performing claims organizations are five times more likely to measure their performance in core competencies, six times more likely to measure claim outcomes based on evidence-based treatment guidelines, and 10 times more likely to measure claim outcomes based on evidence-based disability duration guidelines.

The study graded “performance” by ranking respondents by their claims closure ratio – a common industry benchmark of operational effectiveness.

  1. Best performers invest more in people.

High performing claims organizations better equip and better capitalize on their most important asset: their claims talent. Here’s some proof. Top performers:

  • Arm adjusters with decision support tools known to improve claims outcomes four to five times more often
  • Invest in career-long training of their staff at seven times the rate of lower performers
  • Adopt advocacy-based claims models four times more than lower performers

The best claims organizations use an outcome strategy (versus a process improvement strategy) for success. They measure outcomes, equip their claims talent to better influence outcomes, and allocate more financial resources to outcome management tools.

  1. Best performers invest more in advanced tools and techniques.

When it comes to technology, the most successful claims organizations are far more likely engage in numerous activities. Here are a few:

  • About half of all organizations use a data warehouse today, and usage among high performers is five times the rate of lower performers.
  • Forty-one percent of organizations leverage various outcome-based systems/data, and top performers do so six to 10 times more.
  • Only a third of claims operations use predictive analytics, yet high performers use it eight times more.

How to Close the Performance Gap

With 24 percent of industry payers achieving top performer status, what steps can the remaining 76 percent take to advance their operations?

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Taking stock of the above three differentiators, the commonality is clear. The best claims organizations use an outcome strategy (versus a process improvement strategy) for success. They measure outcomes, equip their claims talent to better influence outcomes, and allocate more financial resources to outcome management tools.

We know employers are predominantly interested in outcomes. Injured workers are only interested in outcomes – theirs.  Millennials entering the claims field today want an environment that helps injured employees with health, functional, and work outcomes. For those claims organizations that choose to close the performance gap, the data and path to success is clear.

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The R&I Editorial Team can be reached at [email protected]