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.

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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 Risk All Stars

Immeasurable Value

The 2017 Risk All Stars strengthened their organizations by taking ownership of improved risk management processes and not quitting until they were in place.
By: | September 12, 2017 • 3 min read

Being the only person to hold a particular opinion or point of view within an organization cannot be easy. Do the following sound like familiar stories? Can you picture yourself or one of your risk management colleagues as the hero or heroine? Or better yet, as a Risk & Insurance® Risk All Star?

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One risk manager took a job with a company that was being spun off, and the risk management program, which was built for a much larger company, was not a good fit for the spun-off company.
Rather than sink into inertia, this risk manager took the bull by the horns and began an aggressive company intranet campaign to instill better safety and other risk management practices throughout the organization.

The risk manager, 2017 Risk All Star Michelle Bennett of Cable One, also changed some long-standing brokerage relationships that weren’t a good fit for the risk management and insurance program. In her first year on the job she produced premium savings and in her second year is in the process of introducing ERM company-wide.

Or perhaps this one rings a bell. The news is trickling out that a company is poised to dramatically expand, increasing the workforce three- or four-fold. Having this knowledge with certainty would be a great benefit to a risk manager, who could begin girding safety, workers’ comp and related programs accordingly. But things sometimes don’t work that way, do they? Sometimes the risk manager is one of the last people to know.

The Risk All Star Award recognizes at its core, creativity, perseverance and passion. The 13 winners of this year’s award all displayed those traits in abundance.

In the case of 2017 Risk All Star winner Steve Richards of the Coca-Cola Bottling Company, the news of an expansion spurred him to action. He completely overhauled the company’s workers’ compensation program and streamlined its claim management system. The results, even with a much higher headcount, were reduced legal costs, better return-to-work experiences for injured workers and a host of other improvements and savings.

The Risk All Star Award recognizes at its core, creativity, perseverance and passion. The 13 winners of this year’s award all displayed those traits in abundance. Sometimes it took years for a particular risk solution, as promoted by a risk manager, to find acceptance.

In other cases a risk manager got so excited about a solution, they never even considered getting turned down. They just kept pushing until they carried the day.

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Butler University’s Zach Finn became obsessive about what he felt was a lackluster effort on the part of the insurance industry to bring in new talent. The former risk manager for the J.M. Smucker Co. settled on the creation of a student-run captive to give his risk management students the experience they would need to get hired right out of college.

The result was a better risk management program for the university’s College of Liberal Arts and Sciences, and immediate traction in the job market for Finn’s students.

A few of our Risk All Stars told us that the results they are achieving were decades in the making. Only by year-in, year-out dedication to gaining transparency about her co-op’s risks and learning more and more about her various insurance carriers, did Growmark Inc.’s Faith Cring create a stalwart risk management and insurance program that is the envy of the agricultural sector. Now she’s been with some of her insurance carriers more than 20 years — some more than 30 years.

Having the right idea and not having a home for it can be a lonely, frustrating experience. Having the creativity, the passion and perhaps, most importantly, the perseverance to see it through and get great results makes you a Risk All Star. &

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Risk All Stars stand out from their peers by overcoming challenges through exceptional problem solving, creativity, perseverance and passion.

See the complete list of 2017 Risk All Stars.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]