In medium- and high-risk industries like construction, logistics, and retail, businesses are feeling the squeeze of rising claims costs. It’s not just an operational headache and a financial threat; there’s a real human cost, as well.
For context, recent data shows self-insured businesses and insurance providers are seeing more workers’ compensation claims, higher liability risks, and increasing property damage expenses. Add inflation, more lawsuits, and tougher regulations, and those costs just keep climbing.
Between 2020 and 2022, the price of materials and labor shot up by 55 percent (Insurance Information Institute), making property claims way more expensive. Insurance rates in high-risk industries have also been climbing, by an average of 12.5 percent annually (Bipartisan Policy Center), forcing businesses to absorb higher premiums and deductibles. On top of that, fraudulent claims and legal system abuse are adding even more pressure, especially when it comes to workers’ comp and liability cases (Insurance Information Institute).
For self-insured businesses, this all means setting aside more money for claims reserves, which can strain finances. For insurers, it leads to higher premiums and lower profits. The good news: There’s an easy way to get ahead of this challenge with a smarter, more proactive approach to managing claims. More on that later in this article.
What’s Driving Up Claims Costs?
One of the biggest reasons claims are getting more expensive is workplace injuries. In industries like construction and logistics, accidents happen all the time — and they’re not cheap. Strains, falls, and equipment-related injuries often lead to long recovery times, rising medical bills, and bigger disability claims. Medical costs for workers’ comp have been outpacing inflation for years, and as the workforce ages, injury severity is going up, leading to longer rehab and higher payouts.
Then there’s property and equipment damage. If you’re self-insured and working with vehicles, heavy machinery, or buildings, you know how expensive repairs can get. Inflation and supply chain issues have made it pricier than ever to fix or replace vehicles, while extreme weather events like wildfires and hurricanes are sending property claims through the roof.
To compound the problem, cargo theft has hit unprecedented levels. One particularly damaging trend is “strategic cargo theft,” where bad actors pose as legitimate carriers to steal entire shipments. These incidents are difficult to recover from and often go unresolved, putting additional financial pressure on carriers and shippers.
The issue has grown so severe that federal lawmakers are now addressing what’s being called “Grand Theft Cargo.”
And let’s not forget about lawsuits. Legal costs are skyrocketing thanks to what’s known as “social inflation” — basically, more lawsuits, bigger jury awards, and aggressive legal tactics. Liability claims are getting hit hard, and with more third-party litigation funding out there, businesses and insurers are seeing more claims head to court, which means even higher costs.
According to insights from Adam Green, Managing Principal at EPIC Brokers, the frequency of bodily injury and property damage claims against brokers has climbed, and longstanding insurers have exited the space entirely. As a result, underwriting standards have tightened dramatically, with insurers demanding more rigorous vetting, raising premiums and deductibles, and increasingly excluding coverage for theft and fraud.
The Human Impact of Rising Claims Costs
Behind the numbers is a very real effect on the people we all serve. Tighter budgets mean tough choices, and cost-cutting often leads to fewer resources for safety programs, delayed equipment upgrades, and even staff reductions. Workers in medium- and high-risk industries face direct consequences, with some having to operate in conditions where safety is less than ideal.
When businesses struggle to keep up with rising claims costs, the risk of workplace accidents can increase, leading to more injuries, longer recovery times, and greater financial strain on employees and their families.
For injured workers, a slow or inefficient claims process can mean delayed medical care, prolonged time away from work, and uncertainty about their financial stability. Higher insurance costs may also force businesses to raise deductibles or shift more costs onto employees, making healthcare and workers’ compensation benefits harder to access. And for small businesses, these rising costs could mean layoffs, reduced wages, or even shutdowns, affecting livelihoods and local economies.
At the insurer level, rising claims expenses mean premium hikes that get passed down to businesses and, ultimately, to consumers. When costs go up across industries like construction and logistics, it can drive up the price of goods and services for everyone. This ripple effect touches workers, businesses, and everyday people who rely on these industries.
At its core, managing rising claims costs isn’t just about protecting a company’s bottom line — it’s about protecting the people behind the business. A smarter, more proactive approach to claims management can help ensure that employees get the care they need, businesses stay financially stable, and industries continue to thrive without unnecessary risk or hardship.
How to Keep Claims Costs Under Control
So, what can businesses do to fight back? It all starts with being proactive.
Preventing accidents before they happen is the best way to keep costs down. Companies in high-risk industries can offer regular safety training and refresher courses, use wearable safety technology to track worker fatigue and posture, and implement AI-driven video monitoring to spot risky behavior.
One of the most effective ways to prevent future claims is to learn from past ones. Incident-based claims and risk management (Cloud Claims) helps businesses do just that by tracking and analyzing every reported incident — whether it results in a claim or not. By capturing near-misses, minor injuries, and equipment failures in real time, companies can identify patterns and root causes before they escalate into costly claims. This proactive approach allows safety teams to address risks early, implement targeted training, and make data-driven decisions to improve workplace safety.
Beyond prevention, incident-based tracking also streamlines claims handling when accidents do happen. By having detailed incident reports readily available, businesses can ensure accurate documentation, reduce disputes, and speed up the claims resolution process. Over time, this leads to fewer repeat incidents, lower claims costs, and a safer work environment for everyone.
Take Control of Your Claims Costs
At the end of the day, businesses and insurers in medium- and high-risk industries need to take a multi-pronged approach to managing claims. That means: preventing claims before they happen with better visibility, stronger safety programs, and better risk analytics; and streamlining claims handling to cut down on delays and unnecessary expenses.
At APP Tech, we’ve helped hundreds of businesses and organizations across North America take control of claims costs with smart automation, incident-based tracking, and intelligent claims triage. If you’re ready to reduce claims expenses and get ahead of rising costs, let’s talk.
https://apptechllc.com/wp-content/uploads/apptech-rising-cost-of-claims@2x-scaled.jpg12852560APP Techhttps://apptechllc.com/wp-content/uploads/logo-color.pngAPP Tech2025-03-24 19:33:062025-03-24 19:33:06The Rising Cost of Claims: How Self-Insured Businesses and Insurers Can Get a Grip on Expenses in Medium- and High-Risk Industries
Sometimes the difference between workplace safety and disaster is less than an eighth of an inch — easy to miss, unless you have the right insight.
Consider a U.S. manufacturing company, where over the course of two months, three employees slipped and fell or almost fell near a finishing station. The good news is that no serious injuries occurred. The other good news is that because this company was tracking incidents, not just formal claims, they were able to get ahead of the problem before anyone got hurt.
Data from the company’s claims-management system had exposed a trend (people slipping near the finishing station), and a quick inspection revealed the issue: a misaligned floor drain causing a small amount of water to pool in the area. It was imperceptible to workers as they focused on their jobs, but the incident data laid bare the risk.
With a simple drain realignment and a slip-resistant floor coating, the company may have prevented costly, avoidable injuries and hardship.
Go on offense: A smarter way to handle claims and keep employees safe
A reactive approach to claims management isn’t very good at identifying risk, and it can force expensive errors. By the time an issue blows up, your team may be left scrambling, service delivery can get messy, and expectations become harder to meet.
That’s why forward-thinking companies are ditching damage-control strategies and tactics in favor of an incident-based system, one that taps into real-time data to prevent problems before they start.
This approach involves tracking near misses and spotting potential hazards before they escalate. By analyzing these insights, businesses can fine-tune safety training, improve protocols, and make data-driven investments in prevention. The result? Fewer injuries, a safer workplace, and a culture that prioritizes employee well-being.
The shift isn’t just about protecting the bottom line. It’s about looking out for the people who keep the business running: employees, partners, and customers.
Creating a better, smoother experience for customers
Risk management isn’t confined to the workplace. If safety hazards, service disruptions, or product defects slip through the cracks, customers feel the impact too.
But businesses that stay ahead of potential issues can catch recurring problems before they escalate. And a big part of that is making sure customers feel heard early on.
When companies formally track client concerns from the start, they’re not just gathering data — they’re showing they care. This builds trust, speeds up issue resolution, and ultimately creates a smoother, more reliable customer experience.
Cutting costs by avoiding unnecessary risks
Preventable incidents lead to expensive claims, legal headaches, and reputational damage. Not anticipating or ignoring risks drives up costs.
On the flip side, a proactive approach keeps the bottom line in check. By averting avoidable claims, businesses operate more efficiently and avoid unnecessary expenditures. Staying ahead of risks isn’t just smart — it’s profitable.
Turning incidents into actionable insights
Shifting to an incident-based approach requires the right tools, processes, and mindset. Businesses need a system to track and analyze incidents in real time so they can make informed decisions quickly.
By combining traditional and AI-enabled analytics, patterns emerge, uncovering and predicting risks before they escalate. And beyond the tech, it’s about creating a company culture that values prevention over reaction, where risk management isn’t just a policy but a core business principle.
The future of risk management: Stay ahead, stay safe
Gone are the days of waiting for problems to arise. A proactive, incident-based approach gives businesses the power to anticipate risks, protect their people, and keep operations running smoothly.
Because at the end of the day, risk management isn’t just about policies — it’s about people. And when businesses prioritize prevention, everybody wins.
An incident-based approach to claims and risk management helps self-insured businesses get ahead and stay ahead by tracking incidents from the start and capturing critical data that may be lost in traditional systems. These insights can help prevent future losses and create a safer work environment for everyone.
The problem with traditional claims-focused systems
Traditional claims-management solutions often prioritize the claims process itself while leaving incidents and near-misses untracked or as separate, loosely connected data points. In these systems, where incidents exist independently, claims managers are tasked with the tedious work of connecting them to claims in a meaningful way.
On top of the extra effort, critical information can slip through the cracks, creating gaps in risk visibility and making it harder for businesses to proactively identify trends and prevent future incidents.
Simply put, most claims-management systems aren’t geared for effective risk management.
What is incident-based claims management?
Incident-based claims management links all relevant data from the moment an incident happens, providing a more complete picture of workplace risks and enabling organizations to act earlier and more effectively.
When an incident — such as a workplace injury, vehicle accident, or property damage — occurs, it is immediately logged into the system. All new information, including subsequent claim information, is seamlessly tied together in a risk management information system (RMIS). From there, the organization can keep tabs on all related details, notify stakeholders, and take necessary actions to prevent further escalation.
This approach puts incidents at the hub and creates a direct link between workplace safety and risk management. (OSHA compliance, for example, is based on incidents, not necessarily claims.) By tracking all incidents — including those that don’t immediately result in claims — businesses can get a clearer picture of their overall risk exposure and can proactively address issues before they escalate.
Why tracking incidents, not only claims, is a smarter move
Instead of just focusing on claims that have already been formally submitted, an incident-based approach gives you insight into everything — from close calls to formal cases to resolution.
Improved cost tracking: One accident can result in claims across multiple policies (e.g., workers’ compensation, property, third-party general liability). An incident-based approach allows organizations to track all related claims together, even when some are managed internally and others by third-party administrators or carriers. This comprehensive view makes it easier to understand total costs at the incident level, aiding in management decisions, self-insurance strategies, and future policy negotiations.
Reduced redundancy: Traditional claims-only systems often force duplicate data entry when multiple claims arise from a single event. By centralizing incident tracking, businesses eliminate inefficiencies and improve data accuracy. Critical data points — such as date of incident, date reported, and description — are only entered once, improving accuracy and reducing administrative workload.
Shared documentation: Incident-based systems allow photos, documents, and notes to be stored and accessed in one place, ensuring consistency and reducing the risk of missing key information.
Natural data flow: Unlike the oxymoronic “notice-only claim” in traditional systems, data in an incident-based system flows naturally from incidents into claims as events unfold, maintaining continuity and providing real-time insight into risk trends.
Pairing this comprehensive data capture with automated notifications and updates ensures that the right people are alerted as soon as an incident occurs, leading to faster response times and better coordination across teams. And keeping claimants informed throughout the process builds trust and improves their overall experience.
Making the switch to an incident-based approach
Switching from traditional claims management tools or manual spreadsheets might seem overwhelming, but it doesn’t have to be. APP Tech’s Cloud Claims makes it easy to adopt an incident-based approach with a user-friendly platform that simplifies data intake and tracking, customizable workflows that fit your business and all its nuance, plus scalable features that grow with your organization.
Staying ahead of claims and risks requires a smarter approach. An incident-based system not only helps businesses manage claims more efficiently but also provides valuable insights that can prevent future losses. By focusing on incidents instead of claims and by capturing and analyzing data early, companies can improve workplace safety, support their employees better, and reduce claim costs.
Ready to improve your claims process? Contact us. We’re happy to give you a Cloud Claims tour and work together to determine if an incident-based approach is right for your company.
https://apptechllc.com/wp-content/uploads/App-Tech-Blog2.jpg5421080APP Techhttps://apptechllc.com/wp-content/uploads/logo-color.pngAPP Tech2025-02-12 14:22:282025-03-24 20:15:48Look at it another way: Why an incident-based approach makes sense for claims and risk managers
When a key employee retires or leaves, the natural reaction is to brace for impact. But panic doesn’t usually solve much, and in fact, these transitions can be perfect opportunities to modernize, simplify, and future-proof your operations: Assess the processes heavily reliant on the departing employee’s knowledge, identify areas for automation or system upgrades, and implement new tech-based solutions to streamline workflows and reduce reliance on individual expertise.
Here’s how one company did just that, and why you should, too.
Retirement-induced modernization
Here’s the story of one of our clients (names have been changed to protect their identity): A midsized long-term care company that operates scores of locations nationwide was gearing up for the retirement of a long-time employee, Stan.
Stan is incredibly detail-oriented, fantastic with numbers, and comfortable wading through vast amounts of data. Our client operated their risk management department efficiently for decades under Stan’s stewardship. The only problem: most of Stan’s “system” ran on spreadsheets, shared folders on the network, and email chains. Although everything was clear to Stan, many hours (often late at night!) were spent tying out numbers and generating management reports. Furthermore, Stan was the only guy who knew the secret sauce to keep this system going.
When the company learned that Stan was retiring, they were smart enough to get ahead of the curve and upgrade long before he was actually out the door. They teamed up with us to roll out Cloud Claims. We were able to bring over all that legacy data and put it to work. That made workflow smoother, processes more consistent, and visibility a whole lot better. The payoff? Fewer manual errors, hours per month saved on reporting, and a stronger future-ready operation.
The problem with knowledge walking out the door
When someone leaves your company, they don’t just take their office plants and Employee of the Month plaque — they take a lot of know-how with them, too. And if that knowledge isn’t properly and thoroughly documented anywhere, your team may be left scratching their heads. You’ve probably heard something like, “Oh, Jeanie always handled that,” and now that Jeanie’s retired, nobody knows what to do next. Suddenly, even the simplest tasks feel daunting.
It’s not just about process — it’s also about the tools. If your operations are relying on spreadsheets, email threads, and/or old server-based systems, it’s possible that your team is fighting an uphill battle. These systems may have worked back in the day, but now they’re clunky and siloed, and when a key person leaves, things start to break down. Teams waste time hunting for information, fixing mistakes, or just trying to figure out how to keep things running. All of this leads to delays, frustration, and a lot of extra work that could’ve been avoided.
A smarter way to manage transitions
Here’s the thing: People leaving their roles is predictable. It’s going to happen! But instead of scrambling, smart companies see these transitions as a chance to improve.
It starts with a look inward, taking stock of what you’ve got. Are your workflows tied to one person’s brain? Are you using systems that made sense ten years ago but feel outdated now? Will any of this scale? This is your chance to be honest about what’s working — and what’s not.
Once you’ve got a clear picture, think about what you are doing manually that could be automated. What’s slowing your team down? There’s almost always room to make things easier and more efficient, whether it’s minimizing repetitive tasks or upgrading to tools that automate processes and free up valuable time for strategic work.
When your processes are consistent and easy to follow, it’s way simpler for new people to step in and get up to speed. And if you prioritize modern tools, your team will get much better access to the info they need to drive the business forward.
Technology as an enabler
Outside of the people you hire, technology is your best ally in smoothing transitions and setting up your org for long-term success.
Here are a few key areas where the right tools can make all the difference:
UX/UI modernization. While spreadsheets and legacy systems may have worked for the retiring or resigning employee who built them, new hires — especially from younger generations — expect modern, user-friendly interfaces. A clean, intuitive UI makes it easier for new employees to be productive quickly and ensures they have the context they need to get the job done.
Automation. Manual processes can slow teams down and increase the risk for errors. Automating repetitive tasks, like claims intake, data entry, and reporting, reduces these risks and frees up your team to focus on higher-value work.
Knowledge management. When knowledge is locked in someone’s head or scattered across email threads, it’s hard to maintain consistency. However, using that knowledge and baking it into workflow workflow rules and event triggers is a great way to capture what works and make this know-how available and helpful to everyone.
Cloud solutions. Server-based systems may have worked when everyone was in the same office, but today’s teams need more flexibility. Cloud-based solutions ensure your processes are accessible from anywhere — whether your team is in the field or working remotely. Plus, they require much less IT intervention, as software updates are automated and infrastructure isn’t needed.
Mitigating risk with proactive planning
Don’t wait for someone to hand in their notice. Prioritize proactive strategies to minimize disruption and reduce future risks.
Here’s how to build resilience into your operations:
Cross-training programs. Don’t let knowledge live with just one person. Make it a habit to cross-train employees so that critical tasks aren’t dependent on a single individual.
Employee-friendly tools. Transitioning to modern solutions, like APP Tech’s Cloud Claims, doesn’t just help your processes — it helps your people. Intuitive tools make onboarding smoother and reduce frustration, keeping your team happier and more engaged.
Continuous improvement culture. Foster a mindset where your team regularly evaluates and updates processes. That way, you’re always improving — not scrambling to fix things when someone leaves.
The bottom line: Transitions are inevitable, but they don’t have to be painful.
Employee departures can feel like a challenge, but they’re also a golden opportunity to modernize and future-proof your processes. With APP Tech’s Cloud Claims solution, you’ll reduce reliance on individual expertise, streamline and automate manual tasks, and improve visibility across your operations.
If that sounds interesting to you, let’s talk. We’ll get a sense for what you’re up against, and if APP Tech can help, we’ll show you how.
https://apptechllc.com/wp-content/uploads/App-Tech-Blog-0122@2x.jpg9641920APP Techhttps://apptechllc.com/wp-content/uploads/logo-color.pngAPP Tech2025-01-23 21:42:282025-03-24 20:12:56Don’t panic: How to mitigate risk when (or before) you lose a claims manager
Founded in 2019 by Michael Lang and Joseph Denneler, Esq., Inspector Claim Management (ICM) specializes in providing claims- and risk-management services to home inspectors and other real-estate professionals. With a focus on helping their clients navigate insurance challenges and mitigate risks, ICM quickly established itself as a leader in this niche industry. The company has grown to serve thousands of home inspectors across the United States, with expert guidance and comprehensive claims solutions.
To enhance their service offerings and address unique operational needs, ICM implemented Cloud Claims by APP Tech. This solution gave them a way to scale operations, comply with rigorous security standards, and streamline claims management.
“Cloud Claims is a fantastic system. It provides great, customizable reporting so we can make decisions quickly and confidently. Everything is very user-friendly, and the data is presented in a very easily-digestible format.
“We’ve never thought of switching, because the product and support are outstanding.”
— Michael Lang, co-founder, ICM
Challenges
Specialized needs, scalability and security, affordability, future-proofing
Michael and his team needed a robust claims-management solution, but most of the platforms they encountered were prohibitively expensive or they lacked the specialized features ICM couldn’t live without. For a startup with ambitious goals, affordability and adaptability were non-negotiable.
Furthermore, ICM’s requirements went well beyond basic claims management. They needed a system capable of integrating complex data flows, including monthly EDI data feeds for carriers, weekly policy updates from the sales team, and imported claims data from other third-parties.
ICM needed a solution that could evolve to keep pace with the business, and any system they considered had to meet stringent security standards to satisfy their insurance partners, while still being easy to use and scalable to match the company’s rapid growth plans.
Why APP Tech?
Expertise, flexibility, cost
ICM chose the Cloud Claims platform by APP Tech for its specialized features, flexibility, cost-effectiveness, and its incident-based approach to claims management. According to Michael, he was struck by how well the team at APP Tech understood ICM’s niche needs and their commitment to delivering a solution that fit perfectly. It wasn’t just about finding software; it was about finding a partner who could help ICM build momentum.
Implementation
Smooth data integration, minimal IT burden, focused support
While anticipating the release of Cloud Claims, ICM implemented an earlier, on-prem version of the APP Tech software called IMS. The migration to Cloud Claims, about a year later, marked a turning point for ICM. As a cloud-based solution, Cloud Claims eliminated the need for installation and ongoing IT maintenance. It provided instant benefits like effortless system upgrades, best-in-class security, and enhanced scalability. The team at APP Tech worked closely with ICM to make sure line-of-business integrations worked smoothly from day one.
Results
Since 2020, ICM has seen incredible growth, and has relied on APP Tech’s Cloud Claims to keep pace. The platform handles complex data flows — such as importing policy information and exporting claims data — while its incident-based software architecture eliminates duplicate efforts and provides a single source of reference for all claim information. This ensures ICM can scale with confidence.
Accelerated policy growth: In the last four years, ICM’s policy volume has increased by more than 86 percent, and as their client base continues to grow, the company is handling significantly more claims (a ~12 percent increase year over year) with the visibility and operational efficiencies Cloud Claims provides.
Faster settlements: Cloud Claims helps ICM mitigate risk for their clients, but when an incident does occur, all the information is tracked efficiently, processes are standardized and automated, and settlements are timely. ICM has helped thousands of policy holders recover from losses, and has settled millions in claims, confidently and without hassle.
Cloud Claims at-a-glance
Clean, user-friendly interface for rapid content entry, processing, and auditing
Rich sets of data available across all claims for use by risk management
Custom reporting and analytics based on ICM-determined filters
Workflow and automation for faster claims processing
Enhanced efficiency in monthly reporting for insurance programs
A solution that scales with the business
“Paul and his team are really good — they check all the boxes. They are super responsive when we have questions or need customizations, and without the software itself, our business doesn’t run efficiently.”
I like to joke that I’ve never had a “real job” because I launched APP Tech, straight out of college with a buddy of mine, Peter. At the time — this was 2003 — I knew I wanted to build software, and didn’t really care what the industry was, but Peter’s father owned a group of transportation companies in the Philadelphia area, and so that’s where we started.
This post will cover a few key lessons I’ve learned in the decades since. Peter left the company in 2005 to dedicate himself full-time to his father’s business (we’re still great friends), and I feel extremely blessed to have helped grow this company from these humble beginnings into a successful software business with an amazing team and hundreds of customers across North America.
More than 20 years ago, my APP Tech co-founder and I started with a simple goal: build meaningful, customer-focused solutions that solve real-world challenges. Simple enough on paper, but from the start, our journey at APP Tech has been a continuous learning opportunity, and no doubt that will continue.
Our first software deliverables were a handful of products designed for a single customer in a single industry. From these early projects, our team and our vision grew, and we’ve learned valuable lessons about listening, adapting, and, above all, the importance of building strong, trusting relationships. Here are a few of those lessons.
1. Embrace outsiders: There’s power in new and diverse perspectives
When my co-founder, Peter, and I started our company, we were winging it. Fresh out of college and with zero industry experience, we had one client, Peter’s father’s transportation company. We knew how to build software and we knew how to ask good questions, that was pretty much all we had going for us.
But after only 18 months in business, we landed a contract to build a claims-management solution for Greater Houston Transportation (GHT). At that time, GHT was the second-largest taxicab company in the U.S. This was a major win, and our industry-outsider status turned out to be a critical factor in closing the deal.
We were at a trade show and met a guy named Raymond Turner — a big, tall Texan with a cowboy hat and swagger. He had worked in tech before, but was a newcomer in the claims world. When he walked by our booth, he saw what we were doing and said something like, “This industry is backwards. It’s out of date, and you have a fresh take on this. That’s going to be really good for us.”
He saw that the transportation industry had become insular, in a way, and was in a rut — confined by the way things were done in the past.
Outsiders see things differently, and can draw new conclusions from the same old facts. They notice opportunities that aren’t obvious to people who have spent too long looking at the same problems and solutions.
Entering the claims industry without conventional experience, our team had a fresh approach, which was to focus on the incidents that lead to claims, rather than starting with claims themselves.
As an outsider himself, Raymond Turner saw the value of our fresh perspective, and he hired APP Tech for GHT. After that deal, we managed to land Total Transit in Phoenix, and APP Tech was off to the races.
Valuing the outsider mindset has since become a defining feature of our work at APP Tech, even shaping our hiring practices to favor diverse backgrounds, passion, and potential over narrow industry expertise. We’ve come to learn that this approach drives innovation and keeps the team focused on real-world problem-solving.
2. Adaptability and intention are key: Find what works, adjust, and focus
APP Tech launched with a suite of three software products — vehicle fleet management, HR compliance, and claims management — all built for the transportation industry. But over our first few years in business, we discovered that the need for our claims management solution cut across industries, and there was ample opportunity in retail, property management, construction, and other fields. We didn’t come to this realization on our own, we heard it from our clients and prospective clients first.
At the time, we were hesitant to pull the plug on our other software offerings, but the writing on the wall became clear: Claims management was worthy of our undivided attention. This was the idea worth building our business on.
APP Tech’s “incident-first” claims management approach, developed from an outsider’s perspective, resonated with clients by offering a unique and practical solution that traditional claims systems overlooked. So, we shifted the team to focus on that one product, IMS, which would later become our flagship offering, Cloud Claims.
We went deep on functionality, user experience, and real-world use cases, ultimately delivering a claims-management system that was distinctive, flexible, and highly reliable — across various industries.
This shift from a diversified product lineup to a specialized focus allowed the team to build a pinpointed solution for a widespread need. Many enterprise solutions attempt to cover too many bases, which often leaves them “a jack of all trades, master of none.” We listened to the voice of the customer, pivoted, and found our niche.
3. Get out there: Customer relationships are your greatest asset
The most impactful interaction I ever had with a client came at a trade show. In 2007, I was manning our booth and having a conversation with a prospect. I saw one of our customers, LaMonte Jackson from Total Transit, walk up and kind of stop. He could hear my conversation, and at some point, he stepped in and addressed the prospect. He said something like, “We work with these guys and they are fantastic.” Then he went on to give us a ringing endorsement.
When the prospect eventually left, I thanked LaMonte for his words, and he just looked at me and shook his head. “No, man. It’s all good,” he said. “You guys are great to work with.” And he reached over and he patted my chest. It kind of shocked me. “Never lose this, man. Never lose that right there.”
This meant so much to me, because I really respect LaMonte. He’s a wise man, and he showed me that he really appreciated not just what we accomplished together, but the relationship we built while doing it. It touched me in a way that has affected my life. Sometimes you feel like you’re working so hard, and sacrificing, and you don’t know if the work is good enough, and you don’t know whether anybody really cares or notices. But to get that kind of feedback from a customer, where it’s all about what’s in your heart, that’s better than any compliment you could give me on our software.
And it gave me encouragement to just stay true to that path, not to lose that heart.
Customer relationships are at the core of APP Tech’s approach. We make it a point to have frequent interactions and on-site visits with our clients — and yes, we still go to trade shows! Because face-to-face time provides unique moments, insights into client needs, and lets us see the real-world impact of our work. Being there in person reinforces our commitment to listening and adapting to serve our clients better. It’s critical, especially in industries where clients prioritize trust and personal connections.
https://apptechllc.com/wp-content/uploads/apptech-blog-12-2-copy-2-1.jpg321687webfxhttps://apptechllc.com/wp-content/uploads/logo-color.pngwebfx2024-12-16 21:34:382024-12-18 13:59:383 lessons from 20+ years of building software
Many organizations use Excel as a claims management solution. Consider that over 1.3 million companies worldwide use Office 365 and can access Excel. Despite its popularity, Excel has many limitations and poses risks as a self-insured organization’s primary claims management tool.
Here are reasons why Excel is not a suitable alternative to a database system or claims management software, followed by the benefits of adopting dedicated software.
1. Scalability Issues
As your organization scales and manages more data, it will need a system that can efficiently handle large data loads. Excel is not that system.
Unlike claims management solutions that have unlimited data storage out of the box, Excel has data limitations. It is not built to handle large or complex datasets efficiently, which can delay claims management processes or produce erroneous results.
Excel also does not support scalability because it is not a document management tool. Users cannot efficiently track and store claim-related documents, images or videos within Excel, hindering the ability to connect data to specific incidents, conduct an effective root cause analysis (RCA) and make meaningful policy decisions.
Lastly, the desktop version of Excel is weak at supporting team collaboration or optimizing workflows due to its lack of built-in workflow tools and integration capabilities.
While some may use Excel as a spreadsheet and pricing tool, it is not the best option for capturing accurate incident-related data. With its limited integration capabilities, managers may not input data immediately following an incident, leading to a greater potential for errors or delays.
Excel also cannot create comprehensive audit trails, and tracking changes is a hassle. Users with editing access can easily delete or modify data in Excel. All of this can make it challenging for auditors to pinpoint the source of an error or validate data accuracy for reporting purposes.
There are better tools on the market designed specifically to enable real time, accurate data capture at the first notice of loss (FNOL) and streamline OSHA reporting requirements. Take APP Tech’s Cloud Claims, for example, which can help make OSHA recordable injuries a much easier process. Switching to Cloud Claims helps you stay on top of risk and regulatory compliance — making your job easier and helping you avoid costly mistakes.
3. Integration Issues
Self-insured organizations handle a lot of data and must communicate this information with insights to various sources efficiently. They require digital tools that enable smooth integration with stakeholder systems — if they want to streamline collaboration and prevent the need to rekey data.
Since Excel was primarily designed without the ability for diverse API integration, it does not support seamless connectivity with a variety of other systems without add-ons. With its inherent API limitations, it can be challenging to collaborate with related systems, leading to inefficiencies in incident reporting, risk mitigation, claims management and payment processing.
For example, Excel may be incompatible with other insurance platforms or tools and, therefore, unable to capture carrier loss runs, which are vital to learning about risks and developing mitigation strategies.
4. Steep Learning Curve
While some organizations hold onto Excel for its perceived ease of use, its lack of intuitive, purpose-built design can actually complicate claims management and impede the user experience.
Unlike dedicated claims management software, Excel does not present claims-related information in a meaningful, easy-to-digest way. It often requires users to adapt spreadsheets using complex formulas and techniques, which can be time-consuming or require a certain level of technical skill. Therefore, maximizing its capabilities can get complicated. Some employees may have difficulty learning Excel, particularly its data analytics features or formula creation. Without an intuitive user interface, organization-wide usage and adoption may be limited.
Claims management software, on the other hand, presents specific, claims-related data in an intuitive and easy-to-understand dashboard upon login, allowing users to gain insight quickly. Specialized software does not require digging through workbooks or scanning lengthy spreadsheets. Users can quickly change views with simple drop-downs.
Common Risks of Using Excel for Claims Management
Data accuracy is important in insurance because it can impact risk mitigation and reserve calculations. With that in mind, Excel’s limitations pose risks for self-insured organizations, particularly in the following areas:
Data Consistency and Management
Managing data and ensuring consistency can be difficult and time-consuming in Excel. As a spreadsheet program with limited automation and integration capabilities, Excel requires more manual input than purpose-built claims management software, increasing the risk of human error.
For example, while users can create formulas to automate calculations, they can also easily input inaccurate formulas, leading to countless and costly mistakes. According to a survey conducted in the U.K., 98 percent of office workers have seen an Excel-related error cost their employer money.
Excel is also known for its issues with version control. With Excel, users may create various versions of the same spreadsheet, leading to challenges in maintaining data integrity. For example, someone might edit an Excel spreadsheet simultaneously, leading to data loss or inconsistencies.
Lastly, Excel’s connectivity limitations may make users struggle to manage data centrally, necessitating manual data entry and increasing the risk of human error. Overall, limited data consistency can hinder efforts to conduct effective RCA, impacting the ability to identify and address risks. A centralized, purpose-built platform, by contrast, provides organizational transparency and more defined access control.
Security Concerns
Where security is a priority, Excel falls short. Excel lacks robust security controls, like advanced encryption features and access permissions, which are common in dedicated claims management software.
Excel also does not make it easy to coordinate access permissions on a granular level. Users typically select “read-only” or “edit” access options when sharing their files. Once a person has edit access, they can change any element in the spreadsheet. If the spreadsheet is shared without any restrictions, it can quickly lead to unauthorized access and leaking of sensitive data. Users may also share Excel files over unsecured channels.
Organizations must implement procedures to ensure data security and confidentiality while using Excel, which may be more complicated than if using more robust software.
Real-Time Reporting
Real-time reporting is essential in risk and claims management processes because it prevents delays between teams and enables risk managers to mitigate risks promptly. Although newer versions of Excel allow data entry in real time, it may not meet the demands of self-insured organizations in field applications.
For example, Excel is available in mobile versions, meaning users can enter data from anywhere. However, using a spreadsheet from a mobile device can be cumbersome, and the mobile version of Excel does not offer all the functionalities of the desktop version. As mentioned earlier, since Excel is not a document management tool, users are unable to attach incident-related documentation to spreadsheet data.
Excel is also not inherently built to distribute reports automatically, adding to an organization’s administrative burden and delaying decision-making and collaboration. So, while Excel may be used to capture real-time data in some instances, it is not designed to notify stakeholders of an incident automatically. The longer stakeholders are not aware of an incident, the longer risks may go unaddressed.
The Benefits of Specialized Insurance Platforms and Tools
Unlike Excel, claims management software is purpose-built for claims processing efficiency and consistency. It is intentionally designed to organize claims-related data, optimize and automate workflows, generate real-time reports, and reduce manual data entry. Claims management software is also created with more robust security controls to help organizations comply with privacy standards and reporting requirements.
Claims management software streamlines data sharing to promote seamless collaboration. It also automates repetitive tasks and enables tailored workflows.
For example, Cloud Claims by APP Tech is built to coordinate claims processing while reducing administrative burden. It enables self-insured organizations to create customized, automated workflows that enhance claims and risk management efficiency.
To illustrate, your team can use Cloud Claims to automatically send notifications of incident or claim activity to key stakeholders at various stages in the claim life cycle. This saves employees from having to notify the appropriate parties manually, allowing stakeholders to be aware of new incidents in real time.
Customization Options
Customization allows organizations to tailor claims management software so it is relevant to specific needs and highlights meaningful insights. Cloud Claims features extensive customization options to support an organization’s unique requirements and simplify data management, including customizable drop-downs and, email templates and key performance indicators (KPIs). Customizable drop-downs allow management to tailor data fields and minimize manual data entry. Managers can centrally manage data and ensure accuracy and consistency throughout the organization.
Software customization also allows teams to treat data segments for incidents, claims, parties, bills and policies uniquely. Organizations can analyze each segment and generate focused reports to showcase specific areas, such as incident-related KPIs.
You can customize Cloud Claims in-house to suit your requirements best — no need to work with developers or undergo extensive training to tailor the system.
Cloud Benefits
Cloud-based solutions are designed to promote simple, streamlined and secure communications. APP Tech’s Cloud Claims is securely stored in the cloud, enabling a single point of truth across various policies and data records without requiring spreadsheet coordination. As team members submit incident details to Cloud Claims, management can access this information from anywhere at any time and gain a comprehensive view of their organization’s risk health. Cloud Claims also offers unlimited file storage, enabling enhanced scalability and team coordination.
Lastly, cloud-based solutions like Cloud Claims offer multiple layers of security, including industry-approved encryption features. As a software as a service (SaaS) provider that maintains a SOC 2 Type II annual report, we hold ourselves accountable for protecting our customers’ data, providing robust security and implementing automatic system upgrades.
Mobile Access
Platforms that allow seamless mobile use do more than offer convenience — they enable organizations to proactively mitigate risks and resolve incidents before employees file claims. Cloud Claims is built to allow accessibility from any device, enabling FNOL from the field. This allows claimants or supervisors to submit FNOL data to Cloud Claims immediately after an incident at the site, allowing for more accurate and timely data capture.
Claims or risk managers can access FNOL data from their phone, tablet or laptop to make prompt decisions. If a claim is filed, claimants and other stakeholders can track the claim status through a portal on their mobile devices, reducing the need for back-and-forth communications.
User-Friendly Dashboards
Software is only valuable if team members use it. Thus, it is important to have an intuitive system. Cloud Claims was designed to allow users of various skill levels to gain insights from data and generate reports quickly, encouraging adoption and enthusiasm. The user-friendly dashboard features a straightforward, drag-and-drop configuration for easy customization. Users can arrange the interface to provide instant insight into selected claim activity upon logging in. For example, risk managers can instantly view loss trends, claim status or other key information they want to see in their dashboard.
Simplified and Robust Reporting
Unlike Excel, claims management software is specifically designed to assist self-insured organizations in collecting and analyzing claims and risk data so they can quickly digest information and improve decision-making with actionable insights. Cloud Claims simplifies data analytics and reporting with turnkey reports for common applications like loss runs. Its drag-and-drop features, such as the ability to group by dragging column headers, allow quick and easy customization. Its intuitive, drag-and-drop functionality also enables ad hoc graphs for fast analysis of live data and rapid decision-making.
Incident-Based Design
Traditional approaches to claims management focus on data analysis after a claim is filed. By contrast, an incident-based approach to claims management emphasizes accurate and timely data collection at FNOL to support effective root cause analysis. It enables teams to learn from near-misses, develop proactive risk mitigation and intervene before a claim is filed.
Cloud Claims is uniquely built with an incident-based architecture to streamline incident reporting and promote efficient risk management. With Cloud Claims, stakeholders can upload photos, videos and documents from the field using their mobile device. The software integrates seamlessly with stakeholder systems and notifies the appropriate parties of incidents automatically. Additionally, stakeholders can easily track multiple claims from a single incident to gain insight into the underlying cause and its financial impact.
Cloud Claims does not require re-keying the same information for different claims connected to the same incident. Other features, like the ability to organize documents by tags or email them to stakeholders directly from Cloud Claims, streamline communication.
Try a Modern Approach to Policy Management Systems
Insurance software is built with efficiency-enhancing features and without the limitations of Excel. If your organization is ready to elevate your claims and risk management processes, consider implementing a purpose-built solution like Cloud Claims.
We can help your organization seamlessly transition out of Excel and into Cloud Claims with tailored onboarding and quick deployment. With our 100 percent successful implementation rate, you can be sure the transition will be seamless. Contact us today to start a conversation or schedule a tailored Demo.
https://apptechllc.com/wp-content/uploads/01-Why-Excel-Is-Not-a-Suitable-Claims-Policy-Management-System.jpg6001195webfxhttps://apptechllc.com/wp-content/uploads/logo-color.pngwebfx2024-12-16 16:16:082024-12-16 16:16:08Why Excel Is Not a Suitable Claims Policy Management System
The role of employers and claimants in the claims process is important, and it begins with the first notice of loss (FNOL). The FNOL is the first content that initiates the insurance claim process. It is the moment the claimant notifies an employer about any damage, loss or injury, before the employer can respond to an incident. With the necessary information from the FNOL report, adjusters can begin investigating and managing the incident and any related claims.
It is important for self-insured companies to report the FNOL promptly because it can help them follow reporting regulations, address risks before they escalate and start the claim process for claimant satisfaction. However, obstacles to FNOL reporting can delay the process and complicate claims management.
To help you avoid these challenges, here are the top five obstacles to FNOL reporting and what you can do to overcome them.
1. Incidents Are Not Reported in a Timely Manner
If the incident is not reported in a timely manner, it may delay the insurance claim and impact FNOL accuracy. Cumbersome and time-consuming reporting processes are a key reason for underreported workplace injuries. When incidents are not reported immediately, important details like the date, time and circumstances of the event may be forgotten or miscommunicated.
Inaccurate or incomplete information can hinder FNOL submission to the third party administrator (TPA) or insurance carrier. It also prevents risk managers from thoroughly assessing risks. This may keep them from finding the root cause and taking proactive measures to prevent future incidents.
Supervisors, too, may be unclear on their responsibilities. For example, if an employee waits several days to report a slip-and-fall accident, by the time they do, the exact location and conditions may no longer be clear. The wet floor may now be dry, or faulty equipment may have already been fixed during that time.
The use of paper-based reporting can slow down the routing process further. If an employee fills out a paper incident report, it may sit on a supervisor’s desk for days before being forwarded to the appropriate department. In contrast, electronic reporting allows employees to report incidents directly from the field.
2. The Organization Lacks a Standard Incident Reporting Process
A lack of reporting knowledge is a common reason for underreporting work-related injuries. Without a standard operating procedure (SOP) for incident or FNOL reporting, employees may not know what to do. For instance, staff must know how much time they have to report an incident, who to notify and what details to include in their insurance claim. Otherwise, it may lead to late reporting.
Supervisors, too, may be unclear on their responsibilities. For example, a supervisor may be unsure whether they need to conduct a full investigation or simply fill out a basic report after an incident. The lack of clarity can have repercussions. It can result in incomplete documentation and missed opportunities to address safety issues.
This could lead to noncompliance with the Occupational Safety and Health Administration (OSHA). OSHA has recording and reporting regulations companies must follow. Standardizing the process helps avoid noncompliance issues, such as fines or penalties.
3. Reports Are Incomplete or Arrive Piecemeal by Various Methods
Disorganized or scattered incident reporting can lead to common claims management challenges. Such challenges could include miscommunication, errors, incomplete information and delays. For instance, if a video of the incident is emailed separately and a hand-written form is scanned and sent through another method. This scenario creates multiple points of contact. That can be confusing and lead to missing details.
This piecemeal approach contrasts with completing the process online in a single platform. Using an online reporting platform ensures information is captured and submitted together. This streamlined approach can help improve the claim’s accuracy, accessibility and compliance.
4. Key People or Teams Are Not Engaged Quickly Enough
Communication and engagement with stakeholders are important during the claims process. The lack thereof may lead to delays in notifying the right people. Such inefficiencies may result in missed deadlines or potential complications.
For instance, if an FNOL is sent via interoffice mail instead of an automated system, it may take days for the relevant team to receive and act on it. This delay may prevent supervisors from capturing the data or conducting an investigation. What if an organization uses technology but does not have automated alerts set up? Supervisors may not receive immediate notification of an incident.
As a result, key details might be overlooked, and the claim may not be resolved effectively. Quick engagement is essential for accurate reporting and timely response times.
5. There Is a Lack of Follow-Up on Cases
When an incident is perceived as non-critical or minor, it can lead to delays in FNOL reporting because it is deemed not serious. The delay can result in missed opportunities for early intervention and proper FNOL submission. Also, if an injury is not promptly followed up on, the employee may not seek necessary medical care. This may exacerbate the employee’s injury and complicate the claims process. And as such, it can potentially lead to the employer facing legal consequences.
Also, who holds accountability for the incident? A lack of follow-up means the incident cannot be addressed or prevented in case of repeat incidents. Effective follow-up practices can help with proper claims management, accountability and preventive measures.
The Role of Technology in Claims Processes
Claims management software helps organizations with claim processing by streamlining incident reporting. Designed for self-insured companies, TPAs and insurance providers, APP Tech’s Cloud Claims helps clients tackle FNOL reporting challenges.
Cloud Claims software is equipped with various features, including:
Incident-based design: Users can easily navigate and manage incidents from start to finish.
Customizable forms: Organizations can tailor their reporting process to their specific needs.
Streamlined workflows: These workflows help reduce delays and optimize timely engagement.
Desktop and mobile optimization: The software facilitates real time reporting from any web-enabled device.
Start Streamlining FNOL Reporting With Cloud Claims
Streamlining your FNOL reporting is an important consideration for any business. With the right tools and processes in place, it can help with efficient claims management and risk mitigation.
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Claims processing involves a series of steps and coordination between multiple parties from the first notice of loss (FNOL) to claim closure. Many challenges can arise throughout this process that can impact decision-making and cause delays. For example, a lack of access to real-time data can lead to an inaccurate incident report, which can delay claim validation and hinder decision-making, ultimately preventing a timely resolution.
Addressing challenges with claims processing is important because it can improve claimant satisfaction. It also empowers your organization to identify risk mitigation opportunities, limit risk exposure and prevent loss.
As a self-insured organization, you can make a difference in handling claims more efficiently, whether you manage them in-house or use a Third Party Administrator (TPA) or insurance carrier to process them.
Here are five ways to enhance claims processing:
1. Streamline Data Sharing
Data is at the heart of claims processing. It enables claims adjusters to validate claims and make fast, informed decisions. Data also equips risk managers to identify and proactively address risks to prevent future incidents — helping to lessen claims management and processing workloads.
If your organization frequently experiences delays or confusion related to data sharing, it may be time to assess your current system. What tools do you use to share data? Do they easily integrate with stakeholders’ systems?
Using outdated or inefficient claims management software, for example, could be at the root of data-sharing issues. If this is the case, consider switching to a new software provider or upgrading to cloud-based technology, if applicable.
Cloud-based technology that allows real-time data sharing and integrates with external systems can streamline data sharing between all stakeholders and accelerate the decision-making process. For instance, with a cloud-based solution, an employee or site manager can directly add incident data and supporting documentation, like photos and videos, into the system from their mobile device. Decision-makers can then view the incident data remotely, almost instantly, and take the appropriate action — before a claim is filed.
2. Identify Opportunities to Automate Repetitive Tasks
Automation can help your business optimize the claims process, free up resources and reduce the risk of error. It allows your team to dedicate more time to improving processes and addressing complex claims.
If you want to use automation to simplify claims processing, the first step is identifying which tasks to automate. Typically, repetitive processes that do not require human judgment are worthwhile candidates for automation.
To help you brainstorm, here are some tasks that you may consider automating:
Adding new fields if an incident goes to litigation
Delegating tasks to the appropriate party
Sending notifications to TPAs, claimants, risk managers and other stakeholders
Generating reports and scheduling distribution of reports
Once you have identified automation opportunities, consider what tools you will use to make it possible. For example, you could adopt claims management software with automated features. If you are considering investing in claims management technology, look for a solution that simplifies automation so users are motivated to use this capability. Features like intuitive navigation and drag-and-drop fields facilitate easy customization of automated tasks, which can encourage users to make the most of automation.
3. Keep Communication Channels Open and Clear
Establishing clear communication channels between your organization and your TPA is essential to streamlining the claims process because it fosters collaboration and enables you to resolve issues and queries quickly. There are various steps you can take to build a simple and standardized communication method.
First, discuss communication methods and expectations with your TPA or insurance carrier. Strive to have an open conversation that allows you to set clear expectations and goals.
Also, consider the technology you use to communicate with stakeholders and whether it facilitates or hinders communication. Claims processing software that offers a cloud-based, centralized platform and seamless integration with other systems can make it easier to relay information as well as receive loss runs from your carrier.
With such a solution, you can efficiently generate financial impact reports based on loss-run data, and stakeholders can access important information, such as incident details and policy provisions, at any time to answer questions quickly or make prompt decisions. Creating a single source of truth can also prevent confusion and miscommunication.
4. Regularly Monitor and Review Key Performance Indicators
If you work with a TPA to process claims, monitoring your partner’s performance can be beneficial. By doing so, you can ensure that the TPA is adhering to your guidelines and pinpoint inefficiencies leading to delays. You can then communicate your insights to your TPA and collaborate on improving processes.
One way to measure how well your TPA handles claims is to track and review key performance indicators (KPIs). KPIs are customizable metrics that allow you to assess performance in specific stages of claims processing.
For example, you might monitor your TPA’s claim cycle time, which measures the average number of days it takes to close a claim and reveals processing speed. If you discover a high claim cycle time, there may be workflow inefficiencies affecting turnaround.
The claim-cycle-time KPI can help start a conversation between you and your partner to identify the root cause of slow claims processing. For instance, you might discover that manual data entry is leading to more errors, impacting claim cycle time. In this case, you and your TPA can determine a strategy to address frequent data entry errors and reduce claim cycle time.
Similarly, you can use KPIs within your organization to identify and address bottlenecks affecting your TPA’s workflow. For example, you might establish a KPI to measure incident response time. This KPI can reveal whether your team responds to incidents promptly. If response times do not meet a predetermined target, you may need to evaluate the tools your organization uses to report incidents.
5. Leverage Configurability to Tailor Workflows
You can take advantage of your system’s configuration capabilities to tailor workflows to users’ needs and minimize manual tasks. Depending on the level of your software’s configurability, you may be able to modify the following to streamline claims management:
Data fields: Adjust fields and drop-downs so employees can easily record relevant claims-related information, like status codes and policy coverage classes.
Email templates: Customize email templates to standardize and expedite communications with TPAs and other stakeholders.
Report templates and filters: Tailor reporting features to enable simplified and meaningful report generation and promote informed decision-making.
Automated tasks: Choose the tasks you wish to automate and modify to meet your team’s workflow requirements.
If your current software is not configurable, consider if it is time to switch to a vendor that offers a configurable solution. Claims management software with user-friendly, no-code configuration tools allows you to easily modify your system to suit your needs. In other words, you will not have to ask a software developer for assistance in customizing your system’s templates, fields and forms.
Intuitive configuration options save you the cost of working with a developer to complete reconfiguration tasks, allow for faster implementation of reconfigured features and give you more control over your workflows — ultimately enabling improved collaboration with your TPA and facilitating streamlined claims processing.
Optimize Claims Management With Cloud Claims
As a self-insured organization, harnessing claims processing strategies that strengthen your partnership with your TPA can be valuable. Taking steps to streamline data sharing helps prevent bottlenecks on both ends and allows you and your partner to focus more on improving.
That said, optimizing claims processing can be challenging without the right tools. You can trust Cloud Claims to transform how you manage claims.
Cloud Claims is our claims and risk management solution designed for self-insured businesses. It supports efficient claims processing by providing these and other advantages:
Seamless integration with internal and external systems
Simplified incident reporting
Automation and customization capabilities
Compatibility features for use on mobile devices
Are you interested in learning more? Please get in touch with us to discuss your needs and schedule a tailored Demo.
On October 11, 2023, the Centers for Medicare and Medicaid Services (CMS) published the long-awaited final rule stating how and when the agency will impose penalties when responsible reporting entities (RREs) fail to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA). The final rule will be applicable on October 11, 2024, and the earliest CMS will impose a civil monetary penalty (CMP) is October 2025. CMS will not impose these penalties retroactively.
The main takeaway from the CMS provisions is it will conduct random audits to identify untimely reports. In the final rule, CMS does not mention penalizing organizations for exceeding error tolerance thresholds or providing contradictory information, contrary to what was initially proposed.
Still, Section 111 compliance is not something to take lightly. CMS will apply a specific CMP amount to each day of noncompliance — which could potentially have a significant financial impact on an organization. We will cover aspects of the final rule that are important to know as a self-insured organization so you can take action now to avoid penalties later.
What Are Section 111 Reporting Requirements for NGHPs?
If you are a self-insured organization that provides workers’ compensation, liability or no-fault coverage, and your company covers the medical expenses of a Medicare beneficiary, you likely fall under the non-group health plan (NGHP) RRE category. As an NGHP RRE, you are required to comply with NGHP-specific Section 111 reporting mandates. CMS provides a user guide to help NGHPs navigate reporting requirements.
The point of Section 111 reporting is to improve the enforcement of the Medicare Secondary Payer provisions of the Social Security Act. These provisions prohibit Medicare from making claims-related payments if a primary plan has already paid for costs or plans to cover expenses. Section 111 reporting helps CMS ensure it pays for covered items and services only after the primary insurer, such as a self-insured organization, has made payments.
Who Must NGHPs Report To?
In general, NGHPs must transmit claims information to CMS electronically through the Benefits Coordination and Recovery Center (BCRC). The BCRC plays a role in managing CMS databases and collecting claims data on behalf of CMS. However, before submitting data, you must first register as an RRE on the Section 111 COB Secure Website.
They have assumed ongoing responsibility for medicals (ORM).
They have paid the total payment obligation to claimant (TPOC).
You must report claim information quarterly unless there is nothing to report.
What Must NGHPs Report?
As an NGHP, you will need to submit details about the claimant, the services provided and the payments made. This includes the following:
Claimant’s Medicare ID or social security number, date of birth, and gender
ICD diagnosis codes
Your organization’s taxpayer identification number
Total amounts paid to the claimant and when they were paid
When Would CMS Impose Section 111 Civil Monetary Penalties?
CMS states in the final rule that it will only impose CMPs if it identifies an occasion where a TPOC or ORM has not been reported timely.
Generally, NGHPs have a year to submit a claims record after making a settlement. If the NGHP provides a record a year after the settlement date, and CMS randomly selects the untimely record during an audit, the NGHP could face CMPs.
How Are CMPs Calculated for Section 111 Noncompliance?
CMS considers whether your organization is a group health plan (GHP) RRE or an NGHP RRE. Unlike GHP entities, which face a penalty of $1,000 for each day of noncompliance, NGHPs are penalized under a tiered system and face a cap on the amount of CMPs that can be imposed. Penalties are adjusted annually to account for inflation.
The tiered method is as follows:
If a record was submitted over a year but under two years of the required reporting date, CMS will impose a penalty of $250 for each day of noncompliance.
If a record was submitted two years past the reporting deadline but under three years, CMS will impose a penalty of $500 for each day of noncompliance.
If a record was reported three or more years after the deadline, CMS will impose a penalty of $1,000 for each day of noncompliance.
The current penalty cap for a single occurrence of noncompliance is $365,000 in a year, adjusted annually. Therefore, if there are multiple instances of noncompliance, CMS can impose up to $365,000 per year, or more when adjusted for inflation, for each instance.
How Will CMS Identify Instances of Noncompliance?
Rather than use an automated process to monitor all RRE submissions, as considered in the proposed rule, CMS plans to assess a random sample of 1,000 records annually or 250 randomly selected reports quarterly. The number of GHP and NGHP records audited is proportional to the volume received.
For example, if CMS receives 300,000 NGHP records and 700,000 GHP records in a quarter, 70 percent of the 250 audited records will consist of GHG submissions, and 30 percent will be NGHP submissions.
Are There Exceptions to Section 111 Mandatory Reporting?
CMS finalized a few safe harbors to protect RREs from penalties under certain circumstances. RREs will not be penalized if the following safe harbors apply:
Untimely reporting resulted from a technical issue outside of the RRE’s control.
Reports were submitted late due to an error caused by CMS.
Claimants did not cooperate in providing the required information, leading to untimely reporting.
Additionally, CMS acknowledges that other situations may make it inappropriate to impose a penalty and encourages RREs to file an appeal if they feel a penalty was unwarranted.
Since CMS has more authority over NGHPs than GHPs, it can also consider “good faith efforts” if an NGHP does not submit a claims record in a timely manner. Good faith effort refers to the NGHP’s documented attempts to obtain claimant details, like social security number, without success. NGHPs must attempt to acquire the necessary information three times to be exempt from Section 111 reporting requirements based on good faith effort.
How Can a Self-Insured Organization Mitigate the Risk of CMPs?
Complying with Section 111 can be challenging. It may be difficult to determine whether a claimant is a Medicare beneficiary, for example, or to obtain the necessary information. Keeping up with reporting timelines may also be tricky without a well-defined process.
To stay on schedule with Section 111 reporting and avoid CMPs, follow these tips:
Simplify Timeliness
The key to saving your organization from Section 111 noncompliance is to submit records on time — but that can be easier said than done. Using a tool like MIR Express™ ensures you do not miss quarterly submission deadlines.
MIR Express™ is a cloud-based Section 111 reporting solution designed specifically to meet the needs of NGHP RREs. It automates monthly and quarterly submissions so you can provide timely records with less effort.
Streamline Data Collection
Collecting the required claim details does not have to be a time-consuming process. Consider integrating your claims management system with a reporting solution to populate claims data into your reports and reduce the need for manual data entry.
For example, MIR Express™ fully integrates with most other claims management systems, including APP Tech Cloud Claims, providing a complete, streamlined solution.
Ensure Accuracy
Even though CMS does not explicitly state that it will penalize organizations for submitting incorrect claimant data, accuracy still matters. Errors can lead to reporting delays and impact timeliness.
With MIR Express™, you can rest assured record submissions are accurate. MIR Express™ provides data pre-validation with a 99.9 percent acceptance rate.
Achieve Section 111 Reporting Compliance With MIR Express™
Although MMSEA’s Section 111 can be complex to navigate, simplified reporting is possible with MIR Express™. Our one-of-a-kind solution will help your organization comply with Section 111 reporting requirements with less hassle and more peace of mind. When you combine this tool with Cloud Claims, you can enhance your entire claims management and risk mitigation workflow.
We would love to discuss your organization’s needs and how we can help as your software solutions partner. Contact us today to begin the conversation.
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