The Art of Healthcare Claims Management

Having extensive experience in the domain, how would you describe the development of claims management in the healthcare industry to this day?

In Healthcare Claims Management, at every point of the process, whether in development or implementation, we must always strive to consider the safety of our residents, patients, and staff, first and foremost. As we see our facility Administrators and leaders intricately working with our staff through education and providing ongoing safety meetings and training, we are seeing better outcomes with the claims in our skilled nursing facilities. In addition to that promising growth, the ever-growing new software, and data opportunities available are allowing us to continue to be on top of protecting our claims management data from cyber-attacks, which has grown exponentially and nationally over the past few years. Development of good processes and protocols to assist with the safekeeping of claims data, along with the collaboration of our carriers and third party administrators (TPA), help us to ensure this is completed and secured on our behalf. Our mindset must be to transition from just filing a claim to showing empathy and displaying resilience, along with using sound judgment by building partnerships and most importantly initiating “best practices” within the healthcare industry. Great claims management is achievable and works when you embrace teamwork, show compassion, have integrity, give respect, and always encourage positivity.

What are some of the new trends that are emerging in the healthcare claims management space?

Inflation is currently affecting all aspects of healthcare claims management. It has a huge impact on the current hard insurance markets resulting in increased premiums, higher deductibles, and more self-payment of claims in workers’ compensation, property, commercial auto, and general liability claims. As a result, these rising costs are causing adjusters, and employee risk oversight personnel to rethink how they can best bring claims to a favorable resolution, and that takes “out-of-the-box thinking” in claims negotiations. Utilizing more strategic negotiation skills that include, but are not limited to, annuities and pay overtime settlements is important to consider in this volatile economy.

And we can’t forget about COVID! Two years after the start of this horrific pandemic, it continues to be attached to claims in healthcare. For example, some states have workers’ compensation presumptions in place which can delay the normal process of handling a claim. In the states that do have the presumption in place, which is predominately used for first responders and healthcare providers, they will receive some type of workers’ compensation benefits if they are exposed in the workplace. At this juncture, we are not sure if these states implementing the presumptions for COVID workers’ compensation will be so indefinitely, or if we will see this particular trend come to an end?

Can you describe some of the challenges you encounter when implementing a seamless claims process in your organization?

One significant challenge we face in healthcare claims management involves the challenge of trying to hold strong to our regulatory processes and protocols while diligently addressing the exertion of claims from our front-line workers. We must work intensely, yet with sensitivity, to enforce our return-to-work program to get the affected nursing staff back to some type of work schedule as soon as they are medically released to do so. If stakeholders are not returning as quickly as they are approved to return to work, the transition back to these hands-on, compassionate jobs can become more difficult. Additionally, challenges can arise with shortages in staffing when you have multiple affected staff while trying to maintain your claims management.

"Finding legacy talent is more difficult each day as new technology evolves forcing them to rely on new software solutions resulting in customer satisfaction reductions and even more challenges associated with the financial outcome of their claims."

But there is a working remedy. The development of good processes and protocols, along with return-to-work programs for transitioning your staff back to work, in a reduced capacity and accordance with their physician’s orders, will extensively mitigate the outcome of a claim. Healthcare organizations that are implementing these return-to-work programs and working with their stakeholders to transition them back into a full work capacity will see greater returns on the financial impact of their overall claims.

Can you give us a brief background about your roles in the organizations you've worked for? How does the experience augment your role and responsibility at your current organization?

I have been handling and had oversight of claims management for 38 years and one word that resonates with me when I am entrenched in my work is “passionate”! I am passionate about every aspect of claims management. I look at every claim as its own and apply my experience in claims management as an overall process for mitigating and bringing each claim to the best resolution for all involved. I have held adjuster licenses in 8 jurisdictions and handled workers’ compensation claims in 5 other jurisdictions not requiring licenses while working for various TPAs for 25 years in the roles of claims adjuster and claims manager. In my current role as Director of Risk Management and Claims at Signature HealthCARE for the past 13 years, I am involved in the operations of the Risk Management program as well as oversight of claims management for workers’ compensation, property, and auto claims, while monitoring, developing, and implementing safety and loss control programs with the team. I have oversight of insurance policies for the company while working directly with our insurance broker and the CFO. My 25 years with third-party administrators have given me an in-depth knowledge of claims in multiple jurisdictions and strengthened my customer service skills, making me very detailed oriented in claims. I have a wealth of experience, knowledge, and understanding of many different circumstances in claims that may lead to litigation and how to reduce that potential because of this recognition and my passion to find resolve. In healthcare claims management, my history in claims handling has enriched my skills as a negotiator and has only strengthened my ability to recognize the root causes of claims, thus resulting in a better overall result.

As an ending note, what is your advice for other senior leaders and CXOs working in the healthcare industry?

My advice would include a few points. First, engagement from all leaders is crucial. Engaging your leaders can help you reduce your overall financial claims burden by having a leading staff member manage and oversee all your claims while working with other leaders, plus the TPAs and carriers. If your residents, patients, and staff know that you care by providing this oversight and direct customer service, this can help inspire more motivated staff members to return to full duty with the appreciation and value they would receive. Secondly, a guarantee of financial downfall in healthcare claims management is ignoring or putting blinders on your claims regardless of the type of workers’ compensation, property, auto, or general liability claims. Having that passion to dive in, think outside the box, and find solutions is key. And finally, carriers and TPAs are facing talent shortages as the most skilled stakeholders are retiring. Finding legacy talent is more difficult each day as new technology evolves forcing them to rely on new software solutions resulting in customer satisfaction reductions and even more challenges associated with the financial outcome of their claims. Utilize your most skilled to educate and train new talent coming into your organizations so that we do not lose the much-needed claims management experience.