Best Practice: What it Takes to Embed Decision Support in Claims

Accurate and effective decision support in claims can impact the trajectory of the claim, reduce its lifecycle and be a critical skill for Resolution Managers to have.
In this month’s Best Practice column, Dawn Griffin, Senior Vice President—Carrier Practice, discusses how carriers can implement decision support to improve claim outcomes.

Q:         What does decision support really mean for carriers?

DG:      There are a couple of different aspects of decision support tools that are paramount—one is how we’re able to leverage the overall trends that these tools and their corresponding analytics produce. Those trends can influence a broader set of claims, and the analytics help us uncover high-level learnings and action items.

                  The other key element you’ll hear me talk about often, is how decision support tools are embedded in the claim process. This is really critical for a successful claim outcome, as it can influence exactly how a claim resolves. Decision support tools can contain complex algorithms that consider more variables and factors than Resolution Managers are humanly able to, but at the end of the day what really matters is how Resolution Managers turn these factors into a superior outcome. To get there, these tools need to be truly embedded in the claims process in a clear, transparent and relatable way. Whether it’s evaluating reserves, selecting medical providers or comparing defense counsel, there are many ways decision support tools can make claim handling easier and more effective.

Q:         In a nutshell, why are these two elements so important when it comes to making a claims decision?

DG:      Leveraging large-scale trends via analytics and being strategic with embedding your decision support tools are equally as important. No matter how sophisticated your tool is, if it’s not married with the process and the Resolution Manager role correctly, it won’t work. The tool itself doesn’t drive change; it has to be embedded properly.

Q:         What are the challenges carriers face when embedding decision support in claims?

DG:      There are several key challenges we see frequently when partnering with carriers to provide a claims management solution. The first is around communicating the complexity of the output, action items, indicators—all of that needs to be simplified in a relatable way so all teams on all sides of a partnership can understand and take action.     

                  Simply flagging a claim does not count as decision support. A good tool helps Resolution Managers understand what issue is at hand and how to translate that issue into a strong action plan.

                  Another recurring challenge we see involves timing: A decision support tool needs to be embedded at the right time in the process. It can’t be overly burdensome to use or respond to. It needs to be a logical, seamless part of the claim process for your team to truly recognize the benefits of it.

Q:         What are the biggest pain points carriers must consider when using a partner to embed decision support in claims?

DG:      A lot of what we look at when we work with carriers to provide a partnered solution to claims management is about understanding the clear benefits for all parties in leveraging a good decision support tool and what outcomes can be expected. It needs to be really clear how this will impact the day-to-day life of the Resolution Manager so this process can be refined, and impact minimized. Whether it’s a nurse triage or review, it’s important that you clearly explain what the tool does, how it’s used and what role the Resolution Manager plays in each scenario. Carriers need to be confident that their business and team have the right level of engagement and are set to receive a truly meaningful impact as a result of embedding a decision support tool.

                  At Gallagher Bassett, we have developed customized tools to enable our carrier partners to integrate decision support into their everyday claims management. We use Waypoint to evaluate reserves, GBCARE to select high-quality medical providers and GBLMP to ensure appropriate and effective defense counsel, as examples of tools focused on intervention and settlement strategy selection.

Q:         What’s one piece of advice you would give to carriers considering a new decision support tool?

DG:      Take your time and find a partner that knows these tools inside and out. Giving your business enough time to embed a tool is critical to how effective it will be, and when you partner with a TPA that understands these tools, you’re likely to experience a much smoother transition. It’s really critical, no matter what tool or partner you choose to implement decision support in your business, that you benchmark and evaluate the severity of claims to ensure your program is working in your favor wherever possible. At GB, we have believed for many years that decision support tools are a necessity for modern carriers. They can truly differentiate successful programs from unsuccessful ones.

To find out how Gallagher Bassett can help you implement effective decision support tools, connect with our team of experts today.

Dawn Griffin

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