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Digital EditionTechnology for Today’s Workers’ Comp Medical Programs: 8 Attributes to Insist On
Managing workers’ compensation medical benefits can be challenging. Health care professional shortages, consolidations and closings of medical practices and pharmacies, more prevalent chronic and mental health conditions among workers, and rising costs are some of the factors that make it more difficult to facilitate medical services for injured workers. On top of all that, we have a widening talent gap for experienced claims professionals.
In response to these circumstances, many (if not all) workers’ compensation organizations are relying on technology — their own and that of their vendors and partners — to manage medical products and services. There is no shortage of technological solutions available, but their features and overall quality can vary widely.
Kristine Kennedy, SVP, product strategy and innovation at Healthesystems, has some tips on what to look for in pharmacy and ancillary benefits management technology.
Kristine Kennedy, SVP, product strategy and innovation, Healthesystems
“Supporting technology solutions are crucial to the success of medical benefits management programs, whether selecting freestanding solutions or partners whose technology you will integrate with and rely on,” said Kennedy. She recommends using the following attributes to evaluate technological solutions to ensure they meet the needs of all stakeholders.
1) Exceptional user experience that is intuitive and simplifies (without reinventing) claims staff’s processes and workflows. Routine tasks should be easy to accomplish, saving valuable time and improving job satisfaction.
“No matter how powerful a technology may be, it will only be adopted and utilized if the user has a positive experience interacting with it,” said Kennedy. “Experienced developers know that inputs such as user research, user acceptance testing and tracking user behaviors via analytics are valuable inputs for the successful development — and ongoing improvement — of tools to support claims teams in their demanding roles.”
2) Advanced analytics that provide meaningful and actionable insights, as well as driving automated decisions. This requires a combination of large data stores and machine learning technologies to draw relevant information from unstructured medical data, in addition to program and transactional data to monitor performance.
Rapid advancements in artificial intelligence (AI) technologies, such as foundational models and generative AI systems, have the potential to deliver great value, but they also introduce new risks. An ethical and responsible approach that balances the benefits and risks of these technologies is essential.
“All analytics and foundational models rely on data which, in our industry, is usually confidential,” said Kennedy. “So, it’s important to know exactly what technologies are being used behind the scenes, as well as understanding the governance policies of all partners.”
3) Right-time clinical guidance to inform therapeutic decisions without delay, as well as integrated clinical intelligence to create rules and automate workflows as much as possible. Current, authoritative clinical expertise should be embedded within the solution to inform decisions and drive automated workflows.
“We understand that the management of prescription drugs and services is just one slice of a claims handler’s role. So, if a prescription authorization gets flagged for their review, it’s our job to make it easy for them to make a decision that will align with clinical best practices and support their organization’s medical management strategies. Serving up relevant education or recommendations at key junctures of the workflow helps them understand the context of the decision in the moment they are making it.”
4) Early risk identification and alerts to facilitate appropriate intervention. Analytics-driven tools based on proven risk indicators should be used to identify and quantify risks for individual patients, as well as within injured worker populations.
“It’s always a small number of claims — the outliers — that drive up costs,” said Kennedy. “Identifying which claims are at risk early on can reduce those costs and improve recovery outcomes by allowing appropriate intervention.”
5) Connectivity to vendors, partners and patients can provide visibility and accelerate referral, authorizations and communications across the health care ecosystem. The ability to connect to multiple services and streamline processes improves efficiency and makes work easier for claims professionals.
“The range of services that we deal with in workers’ comp is expanding, and the more we can technologically integrate with those services, the more efficient we will be,” Kennedy said.
6) Insightful reporting that informs strategy and drives decisions through real-time and consumable dashboards and reports. Timely clinical, financial and program performance information allows fast action to impact outcomes and should be accessible on an as-needed basis.
“ ‘Insightful’ is the key word here,” Kennedy said. “Reports are not helpful if you have to sort through data in search of their relevance.”
7) Configurability to suit the unique needs of your organization and adapt as required. Medical management programs can differ greatly according to services provided, patient population, geographic region and more. A flexible, configurable system that can be adapted to an organization’s preferences goes a long way toward maximizing utility and user satisfaction.
“Workers’ comp health care is a dynamic environment, and agile technology is essential to maintain optimal service levels and operational efficiency,” Kennedy said.
8) Security you can count on to protect patient and program data. Only certified applications with a proven track record of resilience to security threats should be considered.
“Both the health care and workers’ compensation industries are desirable targets for cybercriminals,” said Kennedy. When it comes to protecting health care information, “the importance of high security cannot be overstated.”
This is a high-level checklist, and Kennedy cautioned that the devil is always in the details, so ask a lot of questions and be sure to involve all stakeholders in your decision-making process. These include IT, claims management, clinical and, perhaps most importantly, frontline claims adjusters. “The solution has to work for the people who use it most,” said Kennedy.
Just as important as asking questions is answering them. “Look for a curious vendor,” Kennedy advised. “Partners who probe to fully understand your business, your processes and your preferences are partners who want to get it right.” &
