How Workers Compensation Claims Teams are Optimizing Specialist Interventions and Delivering Better Worker Outcomes

The Challenge

Claims organizations sit at the intersection of an aging workforce, rising medical complexity on claims, and a changing regulatory landscape. 40% of senior claims professionals are already eligible for retirement and industry average turnover rates sit at 15-18%. There is a large skills gap for claims leaders to fill. In addition claims complexity is increasing due to a 35% rise in mental health claims which average 2.5x longer duration. As a result claims organizations are struggling to manage case loads efficiently while still providing the appropriate support for each injured worker. 

This is readily apparent in the way that workers compensation insurers are handling claims that require specialist intervention. Timely engagement of resources like Nurse Case Managers and Medical Case Managers on more complex claims can accelerate worker recovery and speed claim resolution. But current approaches to engaging these resources are reactive using a combination of rules engines and calendar-based engagement. This results in specialist resources that are engaged too late or not at all. 

The Solution

EvolutionIQ has been deployed across 200,000+ lost time claims in the US for over 2 years, including at a Top 20 WC carrier in the US. All partners see measurable impact within 9-12 months. More specifically, at several workers compensation carriers the implementation of EvolutionIQ’s specialist intervention solution has transformed claims handling.

The deployment of EvolutionIQ’s platform has enabled these organizations to design a new workflow for their claims and MCM teams to better support injured workers and operate more effectively. The system proactively identifies high-risk claims and prioritizes them for early intervention. Rather than relying on adjusters’ discretion alone to refer after issues become apparent, the system continuously analyzes claim data, predicting which cases would benefit most from specialist involvement. It enables claims teams to act faster and with greater precision, ensuring that limited expert resources are deployed where they can make the biggest difference.

Our claims excellence platform specifically targets the following three key outcomes for specialist intervention in claims:

• Identify claims requiring specialist intervention earlier, especially those with evolving medically complex conditions and comorbidities like psychosocial factors.
• Detecting claims that might have been overlooked by current processes especially outside the initial 30-day duration window. 
• Efficiently deploy Medical Case Managers (MCMs), recognizing their valuable contribution across a range of medically complex claims while ensuring their targeted deployment to preserve limited expert resources.

To read more about the measured results of these carriers, download the full case study here.

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