Setting a New Standard to Predict Future Medical Costs
WALK, RUN, SPRINT Evolution to Digital Claim Efficiency
We wrote a blog last year about The Elephant in Your Claims Department that struck a familiar chord with many people in our industry from the C-Suite to Service Providers and every claim professional in-between. We received a lot of whispered feedback from our audience, that we candidly addressed some of the greatest weaknesses in the claim process today. We share these insights with you because of our journey working alongside you, observing, and listening to what you told us. But take heart, the first step is acknowledgement, which opens the door to this discussion about what can be done about it in a sequential walk, run, sprint implementation.
Care Bridge International began its research and development ten years prior to launching the company in 2015. Beginning with the study of the accuracy of existing medical forecasting tools, measuring literally hundreds of settled claims, we learned through the measurement of medical reserves, post settlement Medicare Set Aside spend and Life Care Plans that current methodologies used by claim professionals and certified clinical staff are grossly flawed. In fact, existing methodologies have never been proven to be accurate and the research consistently demonstrates that claim handlers under-reserve claims approximately 30% and nurses over-forecast medical exposure by 30% or more. Our quest to discover the best tools for determining medical exposure for claims led us to a data-driven approach. Using machine learning algorithms based upon millions of bodily injury claims can, according to our actuarial reviews and endorsements, forecast care within 7% or greater accuracy AND provide a clear path to precise medical management tasks that can reduce medical exposure by 70% or more and greatly improve claim outcomes.
Along the way, we Beta tested our software with several companies. Our agile approach began with a “self-service” machine learning model that would allow claim professionals to generate their own medical reserve forecasts, cost projections and/or Medicare Set Asides for Workers Compensation claims in under 20 minutes. Despite the excitement about the speed of these results, we quickly learned that claim handlers largely, and with rare exception:
1) Do not know the primary diagnosis for a given claim or the accepted/ compensable body parts, often deferring to defense counsel
2) Do not know which prescribed medications are related to the accepted/ compensable diagnosis/ body part or purpose of the medication
3) Do not know what a given claim’s reasonable medical costs should be anticipated, particularly about surgical/ procedure expectations and costs
Without hesitation, Claim Supervisors and Vice Presidents of Claim organizations acknowledge these claim handler weaknesses and largely do not have any confidence in claim handlers’ ability to properly reserve or identify claim Medicare exposure, even though these tasks are a fundamental responsibility of a claim handler! Ouch!
Given this knowledge gap in the claim process, Care Bridge International pivoted to a referral-based process by which we accept our client’s medical records, and our clinical experts leverage our machine learning software to generate medical forecasts within 24 hours. On a transaction claim basis, our clients select claims for referral and over time, as the collection of claims builds, transparency emerges within the customer dashboard to view not only Care Bridge International's Key Performance Measures, but valuable information about claims, which can be filtered and explored for claim and risk management decision-making.
Our tools forecast the probability of surgeries and procedures and medications offering greater insight into high-cost claim drivers. Our ClaimMAP offers a detailed, claim-specific action plan to quickly execute and collaborate to reduce claim costs with the appropriate parties, to obtain the best clinical outcomes.
For companies embracing digitization and the adoption of claim efficiencies to reduce operating costs and fill talent gaps, our data integration platform is a risk-free rocket ship to claims transformation to meet the expectations of today's C-suite, while improving customer experience and claim outcomes, for long-term sustainability in a changing world.