Data can only help improve claims adjusters if payers, adjusters, providers and claimants communicate with one another.

Physical therapist Greg Nichols, president of SPNet, a division of MedRisk, is a self-described “data junkie.” He loves looking at data to identify whether or not an injured worker is making progress toward recovery and using technology to communicate with other stakeholders.

So when a clinician reported that a worker who was six weeks into treatment for low back pain didn’t seem to be improving, Nichols and his team looked at the data, then went back to the patient. It turns out the patient had radiculopathy, an injury where a spinal disc is encroaching on a nerve.

He needed a different course of treatment.

The technological system alerted the claims adjuster, who had authorized another four weeks of PT treatment even though that process wasn’t working. The provider and the claims team then worked together to move the treatment in a new direction.

Effective data collection, communication and technology systems helped keep this worker’s recovery on track.

“It’s a prime example where the clinician picked up on it, the claimant was telling us, but we would have missed it as the process went through its ‘normal’ action without the assistance of technology,” Nichols said. “There needs to be checks and balances throughout the system.”

From payers and claims adjusters to injured workers and their medical providers, workers’ compensation stakeholders are increasingly using data, machine learning systems and artificial intelligence to track claims progress, identifying and addressing obstacles to recovery before they spiral into major issues.

These tools help providers and adjusters alike track whether or not an injured worker is achieving critical clinical milestones.

But when stakeholders work in silos, they may not have access to each other’s data. A provider might flag a potential issue that could prolong a claim without telling the adjuster. An adjuster may know an injured worker is saying they can’t return to work due to litigation over the claim without telling the physician. In both cases, the other party will wonder why a claim isn’t progressing as it should.

“The methods of communication in the past have holes,” said Skip Brechtel, executive vice president of strategic partnerships with CCMSI. “They slow down the process and slow down the identification of issues.”

Automated systems and other tech tools can help address these gaps in communication by enabling stakeholders to share their data more easily. When everyone works together and discloses relevant claims information with one another, it can speed up recovery times and streamline workflows, resulting in a smoother workers’ compensation system for all.

How Data Sharing, AI and Other Tech Tools Improve Claims Outcomes

Medical providers often use clinical or care pathways to measure a patient’s recovery. These tools outline how long it takes, on average, for a patient to recover from a particular injury and detail the treatment steps and milestones they need to meet.

“In a clinical pathway, there are progressive milestones,” Nichols said. “If a milestone is not met, a clinician is trained to try and identify it and either remove the barrier or change the treatment to progress past the milestone to the next milestone.”

Let’s look at a knee injury as an example. A common workers’ compensation complaint, knee injuries that require surgery follow a fairly straightforward recovery path: A worker has surgery, progresses to walking with crutches, and, if there are no complications, patients should be able to put half or more of their weight on the damaged leg within two weeks.

“If in two weeks that milestone or that clinical pathway had not been checked off, then that insight, that data point would show there’s a problem,” Nichols explained.

Real-time data about whether an injured worker is meeting clinical milestones is invaluable to adjusters. When providers offer that data to payers and adjusters, they can all work together to make sure a worker is recovering in a timely fashion.

“We’re looking at the real-time data,” Brechtel said. “The technical specifications are there, but what’s as important is that I’m learning about, does the claimant have a good attitude? Are they making clinical progressions? Are they showing up on time for their visits or missing visits?”

Adjusters, too, have valuable information to offer providers. At the beginning of a claim, they collect all kinds of demographic data, including age, comorbidities, BMI or other biopsychosocial factors that can help the provider create an accurate recovery plan. Adjusters might also use machine learning or artificial intelligence to scan this data and detect any potential red flags that could derail recovery.

“All of those things are critical for a clinician to know before they even start treating that claim,” Brechtel said. “We capture all of this in data fields.”

These data systems can help workers’ compensation stakeholders tackle any issue that could push recovery off track early on in the life of the claim — a system that improves recovery outcomes and helps save money.

“The sooner we know a claimant is falling away from recovery, the sooner we can incorporate interventions to help try and get that claim back on track,” Brechtel said.

Don’t Silo Your Data — Why Stakeholder Collaboration Is Critical

Though tracking claims and sharing data is critical to producing positive outcomes, workers’ compensation stakeholders often work in silos. Adjusters and payers may not know what actions providers are taking. Providers may not impart relevant details from their conversations with injured workers with members of the claims team.

Added to this problem is the fact that providers and adjusters are often communicating using different kinds of language.

“A provider who’s treating a person doesn’t necessarily understand how a claim is administered. They don’t understand the ecosystem and the lifecycle that a claimant goes through. All they see is the body part that’s hurt and the information they’re getting from an injured worker,” Nichols explained. “And I’m not sure that every adjuster would understand that a milestone was not met if I continue to speak in clinical terms.”

Even when stakeholders both articulate and understand their data-driven insights, they can get lost if there isn’t a technology system in place to help them manage these communications. Adjusters might be managing hundreds of different claims and working with dozens of different providers. Claims messages are going to get lost if they’re delivered solely by email.

“They’re getting emails from at least 10 different vendors,” Nichols said. “Can you imagine trying to manage that much information with no structure?”

MedRisk and CCMSI have worked together to create technology platforms that automate some of these communications. When providers log clinical details, they’re automatically entered into an adjuster’s claims file. And the system automatically alerts relevant parties when an issue occurs. “We can automate a lot of those processes,” Brechtel said.

These tools help providers and adjusters communicate clearly, even though one might be speaking in clinical terms and the other in the language of claims.

“Whether it’s artificial intelligence or business analytics, we’ve created some opportunities to communicate over that bridge in a language that makes sense to all stakeholders,” Nichols said.

A Winning Combination: Accelerating Recovery and Creating a Smoother Claims Process

Sharing data and improving correspondence between workers’ compensation stakeholders help improve the process for everyone involved. Per Nichols, the medical community speaks in terms of two “E’s”: Effective and efficient treatment. “Collaborating with our claims professional through technology on that fundamental concept will improve client outcomes and positively impact the injured worker’s experience,” he added.

“We really want to challenge the workers’ comp system to figure out how to improve the experience of our four major stakeholders,” Nichols said. “If you take those four stakeholders and you agree that data is very important as it comes from each of those stakeholders, then you need to act on it.”

MedRisk partners with CCMSI to facilitate communication and data-sharing between providers, payers, adjusters and claimants. The technological services used in this partnership help ensure all parties are conveying critical information to one another and automated systems make sure no detail is missed.

As part of the partnership, they’ve created a PT widget, where clinicians can score a claim’s progress. If a provider marks a claim as zero, it means the worker is recovering as expected. If it receives a higher score, the adjuster knows issues are occurring. They’re also working on systems that make appointment scheduling and other administrative tasks easier for claimants and their adjusters.

“We’re building much easier ways to schedule that next clinical intervention to keep the process going,” Brechtel said.

Each of these mechanisms makes it easier for a claim to move forward. When claims move seamlessly, workers recover faster and claims have better financial outcomes for payers.

“What we’re trying to do really is improve communication between those four key parties to drive better outcomes,” Brechtel said. “When we do that, everybody wins.”

“How Data Can Help Track An Injured Worker’s Clinical Progress, Improving Efficiency and Efficacy in Claims.” RiskAndInsurance.com, https://riskandinsurance.com/sponsored-how-data-can-help-track-an-injured-workers-clinical-progress-improving-efficiency-and-efficacy-in-claims/