Gia Sawko & Joe Powell, Gallagher Bassett. So you want to be my TPA? 5 Questions You Should Ask Your TPA Today

Transcription

1 Gia Sawko & Joe Powell, Gallagher Bassett So you want to be my TPA? 5 Questions You Should Ask Your TPA Today

2 What you really want to know How smart is your data? Are you stuck in the past? How do I get some time back in my day? Can I get a simple answer on pricing? Millennial contacts, anyone? My quality or yours? How good are your people? 2

3 Question 1: How smart is your data? When assessing outcomes, how do you normalize for claim complexity? Dr. Goodman, M.D. Average Cost Per Claim: $12,000 Handles the most complex claims in his practice Located in a high-cost metro area Dr. Costly, M.D. Average Cost Per Claim: $9,000 Handles lower severity injuries Located in a lower-cost rural area Without normalization, results can be misleading 3

4 Even within a state and industry, claim complexity can vary Percent of Claims by Injury Complexity Group ILLUSTRATIVE Retailer A, California Medical Only (20%) Low (20%) Medium (30%) High (20%) Very High (10%) Retailer B, California We should not compare claim outcomes across these two programs! 4

5 Is your benchmark comparing these claims? Low Complexity Claim Accident: Cut on forearm Claimant Age: 25 Comorbidity: None State: Michigan Very High Complexity Claim Accident: Fractured skull Claimant Age: 55 Comorbidity: Diabetes, smoking State: California 5

6 Ideally, you compare apples to apples $100,000 $90,000 $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 Average Incurred on Closed $- Med. Only Low Medium High Very High 6

7 Understanding complexity allows you to see financial impact of bad safety years (or safety improvements) Complexity Mix - Lost Time Claims (at 12 months) Ve 13% 19% 18% 12% 16% 20% Client 00 Very High 19% 22% 26% 24% 23% 26% High Medium Low 41% 36% 35% 48% 46% 26% 28% 23% 21% 16% 26% 15%

8 This also helps with assessing performance on managing claim outcomes Client Result SMART Benchmark Percent Closed - Lost Time Claims 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12 mo. 24 mo. 36 mo. 48 mo. 60 mo % 53% 73% 88% 93% % 56% 76% 91% % 54% 75% % 58% % 8 8

9 When comparing results across TPAs, be sure to account for as many of these factors as possible Does your benchmark account for: Industry mix State mix Claim maturity Closure rate Reopen rate Loss development factors Mix of accident types, age, part of body, etc. Can you share data on how the benchmark compares to my data on these points?

10 Question 2: Are you stuck in the past? What guidance do your adjusters receive on key decisions? Broad direction Context Decision Support Increasing level of sophistication 10

11 Question 2: Are you stuck in the past? What guidance do your adjusters receive on key decisions? A What are you trying to solve for, and why? B C Is the system actually changing behavior/decisions? What are the results? 11

12 A Purpose: Why is this a good decision to target? Avg Cost of Closed 36 Months $70K $60K $50K $40K $30K $20K $10K $0K $63K TCM Assigned >180 Days 40% lower cost $38K TCM Assigned < 30 Days 12

13 B How are you actually influencing behavior? (It s about trust!) 13

14 C How are you measuring results? Percent Late Intervention (Referrals After 90 Days) 20% 55% reduction in late intervention 9% GB Before Waypoint Clinical Guidance GB After Waypoint Clinical Guidance 14

15 A helpful check-list of questions to ask A B C What are you trying to solve for, and why? Is the system actually changing behavior/decisions? What are the results? Is the system aimed at a specific purpose (decision)? Does it recommend actions, not just provide raw data? Does it provide a rationale and/or confidence level? Was the system tested by claims staff before rollout to ensure efficacy? What is the compliance rate? Do decision makers appear to trust the system? Does the system leave room for human judgment? What are the top reasons for non-compliance? Is decision review part of the management process? Is the system consistently recommending the right action (percent accuracy)? Has decision making improved since implementation? What is the quantified impact on outcomes? 15

16 Question 3: Can I get some time back in my day? What tools do you offer to help me focus on key claims and trends? You seem really happy to be having this root canal today I am. I get to avoid joining a claim review 16

17 Factors important in knowing where to focus Claim Basics Total incurred Duration Litigation status Disability status Reporting lag Surgery indicator Branch Claimant age State / jurisdiction Predictive Analytics & Future Events Claim complexity model Reserving model Narcotics model Upcoming litigation events Upcoming statute of limitations Upcoming Medicare eligibility Risks & Potential Solutions Volatile part of body / severe nature of loss High severity venue Annuity potential Future medical settlement Risk Transfer potential

18 Claim Strategy Dashboard Apply basic filters to limit to large / mature claims Apply advanced analytics filters (SMART Claim Complexity, Waypoint Reserving, Rx Profile Narcotics) Identify claims with potential for action (e.g., future medical settlement, annuity) Full loss run with direct link to LUMINOS RMIS

19 What about broader trends? The New York Times uses data visualization to make a point so why can t we? 19

20 How visualization can help you in risk management 20

21 Question 4: Can I get a simple answer on pricing? How do you charge for managed care services? What s the fine print? Seemingly minor changes to pricing models may drive significant changes to TCOR $300K $250K $200K $150K $100K $50K Estimated bill review expense $258K 53% lower fees $122K $0K Incumbent Column1 (25% of total savings) $9.50 per Column2 bill + 27% of non-bill review savings 21

22 Question 4: Can I get a simple answer? Fees Booked to Claim File Fee Impact included in loss run utilized by carrier at renewal Loss Expense Inflated by bill review expense results in adverse renewal results Higher Premium and Collateral You Pay More Than You Should

23 Don t forget to read the fine print!

24 Compare fees to the benefit of the services rendered Managed Care Savings State California Connecticut Florida Georgia Hawaii Illinois Indiana Kansas Kentucky Maryland Massachusetts Michigan Minnesota Missouri Nebraska Nevada New York North Carolina Ohio Oklahoma Pennsylvania Tennessee Texas Washington Total Number of Bills Total Charges Gross Savings Gross Savings % Total Expense Net Savings $ Net Savings % ,633, ,146, % 75, ,070, % 30 78, , % 1, , % ,273, ,445, % 61, ,384, % , , % 4, , % , , % 6, , % ,726, ,154, % 35, ,118, % , , % 31, , % 4 2, , % , % , , % 6, , % , , % 14, , % 34 61, , % , % , , % 7, , % 50 15, , % , % 3 2, , % , % 73 38, , % 1, , % , , % 10, , % , , % 4, , % , , % 5, , % , , % 7, , % , , % 14, , % 47 42, , % , % 90 67, , % 1, , % , , % 5, , % , , % 13, , % ,335, ,720, % 309, ,410, %

25 Question 5: Millennial contacts, anyone? How has your TPA adapted to millennials? Unknown numbers? Scam Likely? What area code is.702? I m working when you re working! I can only accept texts. 25

26 Question 6: My quality or yours? Exactly what does your quality measure? Audit Functions Outcomes versus scores Empower or bury Task Masters Work, time, impact and results Counter Intelligence AI/EI Work at the outcomes and not the task Create the new adjuster, not take away what made us great 26

27 Healthy Diagnostics Internal and external metrics Both matter separate and apart Both matter as complimentary agents of success Avoid 1,000 cuts and band aids Its all about us 27

28 When we started our career in claims The purpose of the POA: -Current status -Quick summary -WRTBD The reality of the POA: -Copy and Pasted info -Reporting the news -Data Entry -Outdated, sometimes boring Photo Source: Medium.com 28

29 A new dawn Relevant Data + Hands-on audits + Cutting-edge interactive dashboards = Tools to drive best-in-class performance Timeliness Presence of key data points Copy/paste Execution Follow up Visualized results Drill-downs Photo Source: Medium.com 29

30 Things changed, have we?

31 2018 just the beginning Quality Dashboard Provides both Claim Ops and Account Management view of performance Metrics refreshed daily to enable active management of servicing priorities Metric Drill Down Drill down functionality enables our team to navigate down to the claim level for each metric

32 Question 7: How good are your people? How does your TPA celebrate their staff, your team? The science of people and incentives the people factor! 32

33 How good are your people? Where is the next gen of adjusters coming from? Ask me? 33

34 Questions to ask your TPA: A checklist What you really want to know How smart is your data? Are you stuck in the past? How do I get some time back in my day? Can I get a simple answer on pricing? Millennial contacts, anyone? My quality or yours? How good are your people? How to ask When assessing outcomes, how do you normalize for claim complexity? What are the characteristics of the benchmark you re showing me? What guidance do your adjusters receive on key decisions? How do you know that decision support is working as intended? What tools do you offer to help me focus on the claims that matter? What tools do you use to diagnose trends and root causes? How do you charge for managed care services? What s the fine print? What s the impact on outcomes of the services I m using? Who are your claimants today? Can my claimants get the information they need using their smartphones? How do you measure and monitor quality (including audit results)? How do you know whether your program is on track? How do you celebrate successes and recognize top talent? Where are you hiring your next generation of adjusters from?