White Paper

Making Automation Work

Rising Medical Solutions 2016 Workers’ Compensation Benchmarking Study released last month found that higher performing organizations use automated workflows to generate better claim outcomes.


Automation works! Rising Medical Solution’s 2016 Workers’ Compensation Benchmarking Study released last month found that higher performing organizations use automated workflows to generate better claim outcomes. The study reports that 66 percent of the study participants use workflow automation, and just over 50 percent use push technology or predictive modeling to some degree.

This is great news for claims and medical management but can present some challenges when onboarding a new client who requests a slightly different workflow, or when complying with a jurisdiction’s requirements that fall outside the automated boundaries. That’s when automation with override controls may be the solution.

Let’s take a few examples that illustrate the need for UR automation with override controls.

  1. Due date – The jurisdiction due date for utilization review cases is as critical as the due date for issuing indemnity payments to injured workers. While not all states have an established turnaround time for utilization review decisions, in order to deliver timely medical decisions it is critical to have a “due date” built into the utilization review workflow. In a state that does not have a specific turnaround time for completing cases, the “automated due date” may be aligned with URAC standards. For appeals, URAC’s standard is 30 days, which may be an unacceptable automated solution for all clients. In this example, the automated due date will ensure compliance with URAC standards. An automated workflow solution that offers override controls allows entry of an earlier due date to meet client needs, so for example, 10 days instead of 30 days.
  2. Reviewer qualifications – As a general rule, nurses are qualified to approve medical necessity requests but are not permitted to deny requests. This does not mean, however, that a nurse is needed to review every utilization review request in order to identify which requests should be routed automatically to a physician advisor. Medical directors and utilization review teams can use data analytics to predict the types of requests that should be automatically routed to a physician advisor; for example hip, knee, or back surgery. Using these analytics, automated utilization review workflows can have different override controls for specific clients and/or jurisdictions.
  3. Medical necessity review criteria – Commercial guidelines, such as ODG and ACOEM, also have automated rules that can automate referrals and decision-making. If integrated into an automated workflow, the override control may be based on jurisdiction. For example, in Texas ODG’s UR Advisor may be used for auto-routing utilization review cases, and Reed Group’s MD Guidelines may be used to control automated referrals and decision-making for Colorado utilization review requests.

Once the utilization review workflow is automated, with or without override controls, requests and decisions can provide a powerful data set for managing and improving injured worker outcomes and increased workflow efficiency.


To read the white paper on UniMed’s site, please follow this link.

To learn more about UniMed Direct, please visit their website.

Simplify your medical management operation with choices from UniMed Direct. Deploy ReviewStat, standalone software for your in-house medical management, or access our Independent Peer Review Panel and Integrated National UR services.

2017 RIMS

Resilience in Face of Cyber

New cyber model platforms will help insurers better manage aggregation risk within their books of business.
By: | April 26, 2017 • 3 min read

As insurers become increasingly concerned about the aggregation of cyber risk exposures in their portfolios, new tools are being developed to help them better assess and manage those exposures.

One of those tools, a comprehensive cyber risk modeling application for the insurance and reinsurance markets, was announced on April 24 by AIR Worldwide.


Last year at RIMS, AIR announced the release of the industry’s first open source deterministic cyber risk scenario, subsequently releasing a series of scenarios throughout the year, and offering the service to insurers on a consulting basis.

Its latest release, ARC– Analytics of Risk from Cyber — continues that work by offering the modeling platform for license to insurance clients for internal use rather than on a consulting basis. ARC is separate from AIR’s Touchstone platform, allowing for more flexibility in the rapidly changing cyber environment.

ARC allows insurers to get a better picture of their exposures across an entire book of business, with the help of a comprehensive industry exposure database that combines data from multiple public and commercial sources.

Scott Stransky, assistant vice president and principal scientist, AIR Worldwide

The recent attacks on Dyn and Amazon Web Services (AWS) provide perfect examples of how the ARC platform can be used to enhance the industry’s resilience, said Scott Stransky, assistant vice president and principal scientist for AIR Worldwide.

Stransky noted that insurers don’t necessarily have visibility into which of their insureds use Dyn, Amazon Web Services, Rackspace, or other common internet services providers.

In the Dyn and AWS events, there was little insured loss because the downtime fell largely just under policy waiting periods.

But,” said Stransky, “it got our clients thinking, well it happened for a few hours – could it happen for longer? And what does that do to us if it does? … This is really where our model can be very helpful.”

The purpose of having this model is to make the world more resilient … that’s really the goal.” Scott Stransky, assistant vice president and principal scientist, AIR Worldwide

AIR has run the Dyn incident through its model, with the parameters of a single day of downtime impacting the Fortune 1000. Then it did the same with the AWS event.

When we run Fortune 1000 for Dyn for one day, we get a half a billion dollars of loss,” said Stransky. “Taking it one step further – we’ve run the same exercise for AWS for one day, through the Fortune 1000 only, and the losses are about $3 billion.”

So once you expand it out to millions of businesses, the losses would be much higher,” he added.

The ARC platform allows insurers to assess cyber exposures including “silent cyber,” across the spectrum of business, be it D&O, E&O, general liability or property. There are 18 scenarios that can be modeled, with the capability to adjust variables broadly for a better handle on events of varying severity and scope.

Looking ahead, AIR is taking a closer look at what Stransky calls “silent silent cyber,” the complex indirect and difficult to assess or insure potential impacts of any given cyber event.

Stransky cites the 2014 hack of the National Weather Service website as an example. For several days after the hack, no satellite weather imagery was available to be fed into weather models.

Imagine there was a hurricane happening during the time there was no weather service imagery,” he said. “[So] the models wouldn’t have been as accurate; people wouldn’t have had as much advance warning; they wouldn’t have evacuated as quickly or boarded up their homes.”

It’s possible that the losses would be significantly higher in such a scenario, but there would be no way to quantify how much of it could be attributed to the cyber attack and how much was strictly the result of the hurricane itself.

It’s very, very indirect,” said Stransky, citing the recent hack of the Dallas tornado sirens as another example. Not only did the situation jam up the 911 system, potentially exacerbating any number of crisis events, but such a false alarm could lead to increased losses in the future.

The next time if there’s a real tornado, people make think, ‘Oh, its just some hack,’ ” he said. “So if there’s a real tornado, who knows what’s going to happen.”


Modeling for “silent silent cyber” remains elusive. But platforms like ARC are a step in the right direction for ensuring the continued health and strength of the insurance industry in the face of the ever-changing specter of cyber exposure.

Because we have this model, insurers are now able to manage the risks better, to be more resilient against cyber attacks, to really understand their portfolios,” said Stransky. “So when it does happen, they’ll be able to respond, they’ll be able to pay out the claims properly, they’ll be prepared.

The purpose of having this model is to make the world more resilient … that’s really the goal.”

Additional stories from RIMS 2017:

Blockchain Pros and Cons

If barriers to implementation are brought down, blockchain offers potential for financial institutions.

Embrace the Internet of Things

Risk managers can use IoT for data analytics and other risk mitigation needs, but connected devices also offer a multitude of exposures.

Feeling Unprepared to Deal With Risks

Damage to brand and reputation ranked as the top risk concern of risk managers throughout the world.

Reviewing Medical Marijuana Claims

Liberty Mutual appears to be the first carrier to create a workflow process for evaluating medical marijuana expense reimbursement requests.

Cyber Threat Will Get More Difficult

Companies should focus on response, resiliency and recovery when it comes to cyber risks.

RIMS Conference Held in Birthplace of Insurance in US

Carriers continue their vital role of helping insureds mitigate risks and promote safety.

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]