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.

When Must NGHPs Report?

NGHPs must report claim data for Medicare beneficiaries after either of the following has occurred:

  • 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.

Has your organization recognized a need to shift from manual processes? Are you interested in streamlining incident reporting, risk management and claims processing?

You may be considering investing in a risk management information system (RMIS). An RMIS consolidates all data related to claims, incidents and insurance policies and stores it in a centralized location. It provides a complete picture of how well an organization handles claims and addresses risks while increasing workflow efficiency.

Investing in an RMIS or switching to a new vendor could be fruitful. However, it requires carefully considering what you need in an RMIS and whether a particular solution meets those requirements. The following are the most important things to consider when buying an RMIS.

1. Is the RMIS Secure?

As a self-insured organization, you likely handle massive amounts of valuable data, including financial information. All this data calls for strong security measures to protect your company and customers from cyber threats. Considering that the average cost of a data breach in the United States was $9.48 million in 2023, it is worth placing security high on your RMIS checklist.

To ensure an RMIS is secure and promotes compliance with data protection laws, look for a vendor that can provide a SOC 2 Type II compliance report. This report confirms that the vendor’s RMIS successfully underwent a third-party audit to evaluate the security, confidentiality and privacy of its internal controls.

2. Is the RMIS Cost-Effective?

RMIS solutions are not all the same. It is important to consider various pricing models, ongoing maintenance costs and potential customization capabilities to select the most cost-effective option for your organization.

For example, if you choose a software-as-a-service (SaaS) RMIS, the SaaS provider will likely handle software maintenance and upgrades as part of its service. By contrast, an on-premise solution requires internal IT members to maintain and update your RMIS. An on-premise RMIS adds to the workload of internal IT staff or potentially requires seeking external IT support — which may not be the most cost-effective for your organization’s needs.

Once you have identified an RMIS vendor that could be a viable partner, contact them for an ROI analysis. An ROI analysis will reveal the benefits you can expect from the RMIS compared to its cost. At APP Tech, we can provide a company-specific ROI analysis following a Demo of Cloud Claims, our RMIS solution.

3. Does the RMIS Integrate With Other Systems?

One of the greatest advantages of an RMIS is its ability to integrate with various internal and external systems. Integration capabilities simplify data collection, reduce errors related to re-keying information and enhance collaboration between all stakeholders, increasing claims and risk management efficiency overall.

To get the most value from your RMIS, look for a solution that integrates with your current human resource and accounting systems so you can easily access employee and financial data to generate accurate analytical reports. Also, consider an RMIS that will integrate with your Third Party Administrator (TPA) and insurance carrier systems through tools like application programming interfaces to enable streamlined claims processing.

4. Is the RMIS Scalable?

A scalable RMIS will easily adapt to your organization’s evolving needs and support business growth. In other words, whether you have 100 or 1,000 employees, your RMIS will accommodate your risk management requirements.

Here are features to look for in a scalable RMIS:

  • User-definable data fields
  • Configuration capabilities that do not require IT intervention
  • A pricing model that is independent of claim volume
  • Unlimited data storage

5. Does the RMIS Streamline Incident Reporting?

An RMIS should simplify capturing incident data and sharing it with the right stakeholders at the right time to enable proactive risk mitigation. By streamlining incident reporting, an RMIS also allows key stakeholders to intercede before a claim is filed, potentially saving your company incident-related costs.

The following RMIS features can facilitate efficient incident reporting:

  • The ability to upload documents, photos and videos remotely
  • Seamless integration with stakeholder systems
  • Documentation management capabilities
  • The ability to automatically notify stakeholders of incidents
  • Modifiable incident report templates

6. Is the RMIS Easily Customizable?

Choose an RMIS that you can easily customize to suit your organization’s needs, which does not require you to work with a developer. For example, an RMIS that features customizable fields and drop-downs allows you to tailor the system to your line of business and define elements like claims types, policy coverage class and loss categories.

With the ability to customize the RMIS to suit your organization and its risk managers, claims adjusters and other staff, you can foster higher productivity. Your employees may also appreciate the easy navigation and enhanced user experience of a relevant and adaptable RMIS.

7. Does the RMIS Offer Robust Reporting?

Today’s businesses can harness technology to collect, aggregate and analyze risk data, enabling them to make enhanced, financially impactful decisions. For instance, in a 2023 survey of data and analytics executives, 92 percent claimed their organizations saw measurable value as a result of investing in data and analytics.

However, simply having data does not mean it will be put to good use. Consider choosing an RMIS that will facilitate fast, data-driven decisions so your organization can improve its risk mitigation efforts. Look for features such as:

  • Visualization tools to present data in an easy-to-digest way
  • Ready-to-deploy reports for frequent applications, like loss runs
  • Integration capabilities to enable easy data transfer between systems and ensure data integrity
  • Customizable dashboards, report libraries and filters to tailor reporting to match your needs
  • Simple report generation and streamlined sharing options
  • The ability to easily export data to external business intelligence engines

8. Is the RMIS User-Friendly?

An RMIS is only valuable if employees use it. If an RMIS has a complex navigation system or a cluttered design, for example, employees might get frustrated and avoid adopting the solution. Conversely, a user-friendly RMIS engages users and has a positive effect on widespread solution adoption, enabling improved data capture and increased insight.

To ensure employees embrace your RMIS and utilize it to its potential, look for a solution that highlights user-friendliness. This includes qualities such as:

  • A simple, organized and attractive dashboard
  • Intuitive navigation
  • Global search functionality

9. Does the Vendor Provide Training and Support?

Regardless of how intuitive the system is, efficiently and effectively integrating an RMIS into your workflow can be challenging without the right support. Choose a RMIS provider that offers technical assistance and adequate implementation support to ensure your organization successfully adopts the solution. Your RMIS vendor should help you integrate the solution with your other systems and make sure you understand how to navigate and use it fully.

At APP Tech, we offer tailored onboarding and unlimited support to maintain our client’s success. Providing unlimited support to clients enables a client’s success after the custom onboarding process is completed.

10. Does the Vendor Have a Reputation of Excellence?

The vendor’s trustworthiness and quality of service are just as important as the RMIS itself. Take time to research the vendor, read reviews and evaluate the company’s reputation.

Overall, an RMIS vendor should give the sense that you can trust their team to provide a secure and reliable solution. You will also want to confirm that they will respond quickly to any concerns and are eager to form a supportive, long-term partnership.

Here are a few questions to ask a potential vendor when determining if they are the right fit for your organization:

  • What experience do you have?
  • What problems does your solution solve?
  • What methods do you use to ensure data protection and privacy?
  • Do you have a SOC 2 Type II compliance report?
  • What is your approach to updating and maintaining your RMIS?
  • Can you provide customer references?

You Can Have Confidence in Cloud Claims

An RMIS can improve your organization’s risk management approach, increase productivity and reduce risk exposure, ultimately resulting in cost savings and enhanced claimant satisfaction. Considering the impact an RMIS can make, it is worth choosing a solution that meets all your criteria, provides ongoing tech support and will scale with your business.

You can end your search for an adaptable and intuitive RMIS with Cloud Claims, our flagship claims management platform designed for self-insured organizations. Our scalable, cloud-based solution introduces an incident-based approach to claims management, meaning it streamlines incident reporting to promote data accuracy, enhance decision-making and improve risk mitigation.

Contact us today to learn more about Cloud Claims and schedule a demo tailored to your company.

 

Cloud computing refers to services delivered via the internet rather than on-site hardware or software. The concept of being able to access programs and data from anywhere, traces back to the 1960s, though the term “cloud computing” was not coined until 1997. Today, cloud computing is a tool commonly used by businesses — including organizations that deal with claims processing.

According to the Top Actuarial Technologies of 2022-2023 report, 69 percent of actuaries use cloud computing or storage frequently or often. This is not surprising, as cloud technology offers benefits ranging from increased efficiency to decreased IT-related costs. McKinsey and Company found that the EBITDA run-rate impact of cloud technology on the insurance sector will be as much as $110 billion by 2030.

Like any business wanting to cut costs and boost efficiency, self-insured organizations are harnessing the power of cloud computing to revamp and optimize their claims management process. Here are some of the ways cloud computing is transforming claims processing:

Enables Organizational Optimization

Cloud technology enables self-insured organizations to operate in a way that is not possible with on-premise solutions. Rather than every reporting party adding more claims management responsibilities to a site manager’s workload, cloud technology allows many sites to delegate tasks to the claims adjusters.

When claims-related tasks are seamlessly assigned to the right people, organizations can process more claims without hiring additional staff or taking site managers away from customers and projects. They can envision and incorporate ways to use cloud-based tools to streamline claims management, and ultimately, they can scale faster.

Facilitates Access to Real-Time Data

Self-insured organizations, insurance carriers and Third Party Administrators (TPAs) handle vast quantities of data to process claims, analyze trends and make informed decisions. This data may be stored in databases as part of a legacy system.

The term “legacy system” often refers to outdated hardware or software applications that a company relies on daily. Typically, legacy systems are no longer available for purchase or can no longer receive updates. They may also struggle to handle large data volumes or integrate with external systems efficiently. Without the ability to integrate with new systems and applications, legacy systems maintain siloed databases and hinder efficient workflow.

An alternative is to migrate data and applications to the cloud. Cloud computing outshines legacy systems when it comes to accurate data capture because it enables access to real-time data. Self-insured companies rely on cloud solutions to easily access and share real-time data across departments.

A simple flow of data allows organizations to make informed decisions quickly to mitigate risk, enhance collaboration between teams and prevent errors related to manual data entry. It also enables self-insured organizations to keep employees updated on claim status. For example, our cloud-based claims management solution, Cloud Claims, provides real-time updates on claim status, fostering increased employee satisfaction.

Considering the advantages of real-time data access, it is no surprise that most businesses aspired to have 80 percent of IT-hosting dollars go to the cloud in a 2021 report.

Increases Claims Management Efficiency

Efficiency is the driving force behind successful businesses because it saves time, resources and money while improving customer satisfaction. The same idea applies to claims management. Efficient claims management allows a self-insured business to maximize its time and resources and improve employee morale.

Thanks to cloud-based claims processing solutions, self-insured businesses no longer need to wade through paperwork or get lost in data siloes. Cloud solutions have transformed traditionally sluggish processes into streamlined operations. Here are some of the ways cloud-based software boosts claims management efficiency:

  • Access data anywhere: As long as the users have an internet connection, they can access cloud-based claims management software from a mobile device. This allows companies to initiate risk management actions at the first notice of loss (FNOL) before a claim is even filed.
  • Store data in a centralized location: Cloud-based solutions seamlessly integrate with many types of internal and external software, allowing organizations to keep all data related to claims and incidents in a centralized location. This provides a complete picture of an organization’s risk and claims management health.
  • Easily collaborate with stakeholders: With the ability to centralize data, cloud-based software can provide a single source of truth. This capability means it is much easier to prevent data silos and miscommunication and simplify collaboration among stakeholders.

Cloud Claims also offers additional efficiency-related advantages, as it:

  • Enables self-insured companies to create multiple claims from a single incident.
  • Makes it easy to capture FNOL data remotely and quickly report incidents using customizable fields.
  • Provides automation features, like triggered email notifications, to save time and keep stakeholders informed.

Reduces the Need for On-Premise Infrastructure

On-premise infrastructure requires organizations to keep servers, storage devices and networking equipment on-site. It also requires resources, like time, money and employees to maintain the systems.

Migrating claims management to the cloud reduces the need for on-premise servers, decreasing costs related to keeping and maintaining hardware. According to Nucleus Research, companies see a $3.43 return for every dollar spent on cloud migration. So, while some businesses are hesitant to invest in cloud migration, many recognize that the cloud brings a higher ROI than on-premise solutions.

Adopting cloud-based claims management software can be a quick and painless process, depending on the vendor and type of cloud computing model you choose. Cloud Claims, for example, is a software-as-a-service (SaaS) platform. This means we handle everything related to software maintenance, including implementing automatic updates and offering unlimited tech support.

Promotes Easy Scalability

A business that utilizes scalable resources is equipped to handle rapid growth efficiently. For self-insured organizations, a scalable claims management system is part of that equation.

Some cloud-based claims processing software, like Cloud Claims, are highly scalable due to built-in features such as unlimited storage and customizable templates. Overall, cloud-based software is more flexible than on-premise solutions and allows self-insured companies to scale up or down to meet changing needs.

Simplifies MMSEA Section 111 Compliance

Cloud computing is not just helping self-insured businesses transform how they process claims — it is also revolutionizing how they comply with MMSEA Section 111.

Organizations that make payments to Medicare beneficiaries must comply with reporting requirements under Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007. MMSEA Section 111 reporting can be complex, as it may involve establishing a secure electronic data exchange, collecting detailed information about each claimant and submitting detailed reports. Failure to comply with MMSEA Section 111 reporting can lead to hefty fines.

Fortunately, cloud-based claims management solutions can simplify MMSEA Section 111 compliance by:

  • Allowing your organization to collect, store and access the required documentation easily.
  • Automatically providing a secure data exchange.
  • Reducing human error by decreasing the need for manual processes.

Additionally, your cloud software provider may keep you updated on compliance changes so you do not have to invest too much time in monitoring updates.

We offer MIR Express™️ , a purpose-built, cloud-based solution for Section 111 reporting. To ensure reporting accuracy, MIR Express™ features automated monthly and quarterly reporting submissions and a data pre-validation acceptance rate of 99.9 percent. We keep the product up to date to ensure compliance with MMSEA Section 111.

Choose Cloud Claims to Transform How You Manage Claims

With its ability to increase efficiency, scalability and cost savings, cloud-based claims management software is here to stay. Furthermore, adopting a cloud-based solution can be smooth and hassle-free with the right provider.

For example, Cloud Claims integration and training is a quick process. In some cases, we can have Cloud Claims up and running in a day. We have a 100 percent successful implementation rate, and we will tailor onboarding to your organization’s needs to ensure you feel confident using our SaaS solution.

Ready to learn more? Contact us today to speak with a consultant and schedule a Demo customized to your organization.

 

Key performance indicators (KPIs) are metrics used to evaluate and benchmark performance. Their purpose is to help businesses measure and monitor progress toward set goals. If a company looks at its KPIs and discovers it is not on track to reach a specific target, it can then identify and address inefficiencies.

In the claims management realm, self-insured businesses can use key performance indicators to figure out what is working and what may need improvement. For example, by monitoring a KPI that measures incident response time and comparing it to the target, an organization can determine if its team has efficient risk mitigation procedures.

KPIs are not always one-size-fits-all — you can create your own KPIs to match your business’s needs. To develop claims process KPIs, you will generally want to take the following steps:

  • Determine your goals and objectives.
  • Set a benchmark target to help you measure progress over a given amount of time.
  • Consider your current data sources or establish new data collection methods.

Your company can begin making more informed decisions with a few basic KPIs. The following are examples of claims management KPIs:

1. First Notice of Loss Response Time

First notice of loss (FNOL) response time illustrates how quickly claims adjusters respond to a reported loss. This KPI helps pinpoint inefficiencies in FNOL reporting or response. This KPI is especially important for organizations that may wish to intervene on select incidents before a claim is filed.

One way to create a KPI to gauge FNOL-related performance is to compare the average time it takes for claim adjusters to respond to FNOL reports to the number of FNOL reports in a certain span of time. You can then compare that number to your benchmark target and gain some insight into your current position.

For example, envision a KPI that reveals a 10-hour FNOL response time per incident. If your target FNOL response time is eight hours per incident, your next step could be contemplating strategies to streamline FNOL reporting and response. You might explore the causes of FNOL response delays first, like data entry errors. Then, consider adopting a solution that promotes accurate FNOL data capture, like incident-based claims management software.

2. Claims Frequency Rate

Claims frequency rate refers to the ratio of claims to a chosen base within a specific time frame. For example, you might track the number of claims to a certain number of employees over six months to calculate your claims frequency rate. This KPI can help your organization determine the efficacy of its risk management strategies.

To illustrate, imagine your company wants to decrease its claim frequency rate by 5 percent over the next quarter. In this case, you would first create a KPI to measure and monitor your current claims frequency rate.

For example, you might calculate the average number of claims per 100 employees filed in a month. Then, you could benchmark that number against your goal to see if your company is on track. If your claims frequency rate increases or does not move closer to your target, consider ways to decrease the rate. This may mean improving your risk management process, for instance.

3. Claim Closure Ratio

Claim closure ratio compares the number of opened claims to closed claims. It provides insight into whether a company efficiently manages claims. This KPI can help determine if improvements to claim processing efficiency are necessary.

A claims closure ratio of 100%, for example, may indicate that a company has an effective claims management process, closing claims at the same rate as opening them. A lower claim closure ratio means that an organization opens claims at a greater pace than it closes them, which can suggest performance issues or system inefficiencies.

To determine your claim closure ratio, divide the number of claims closed by the number of claims open. Monitor this ratio, which you might convert into a percentage, over a specific time period to understand your organization’s claims processing performance.

4. Claims Cost Per Closed File

Claims cost per closed file (CCCF) measures the average cost of processing and closing a claim. By monitoring CCCF, you can identify patterns leading to increased costs — so you can then take steps to change them.

For instance, CCCF might reveal that claim adjusters are not utilizing automation to streamline their workflows, contributing to labor costs. In this case, it might be worth evaluating your current claims management software for barriers to optimal system use, like user experience issues. If you discover usability challenges, consider adopting a more intuitive claims management solution.

5. Claim Cycle Time

Claim cycle time measures the average number of days to close a claim. It highlights claim processing speed and is another important KPI for monitoring performance efficiency. Additionally, this KPI is important for organizations that seek to optimize claim outcomes by minimizing turnaround time.

You can determine claim cycle time by identifying the number of days it took to close claims within a certain time frame from their corresponding FNOL dates and calculating an average. A lower claim cycle time can protect your reserves and promote claimant satisfaction, whereas a higher claim cycle time can do the opposite. Refining workflows and minimizing manual data entry are some ways to reduce claim cycle time.

6. Subrogation Recovery Rate

Insurance companies miss out on about $15 billion in subrogation dollars annually. Factors like insufficient communication and lack of supporting documents can hinder successful subrogation recovery.

If you are concerned about your company’s subrogation results, consider monitoring your subrogation recovery rate and implementing strategies like enhancing FNOL data collection to improve it.

Subrogation recovery rate measures the amount of subrogation dollars recovered within a period of time. You can compute this metric by dividing the total number of subrogation dollars recovered in a given period by the total amount paid to claimants. This KPI can provide insight into the timeliness and effectiveness of your organization’s subrogation efforts.

Create and Monitor KPIs With Cloud Claims

KPIs give self-insured businesses insight into their processes so they can monitor progress toward goals and make strategic decisions on how to improve. Any self-insured organization, regardless of industry, can benefit from using KPIs to understand where their performance ranks. Fortunately, integrating KPIs into the management workflow can be straightforward and seamless with the right claims processing system.

For example, Cloud Claims by APP Tech is cloud-based claims management software that helps self-insured businesses, Third Party Administrators (TPAs) and insurance carriers create and monitor KPIs. Cloud Claims offers the following:

  • User-friendly, modifiable dashboard
  • Customizable reports and drop-down menus
  • Subrogation, deductible and recovery tracking
  • Widgets to monitor claims from incidents, claims cost per quarter, incident types by month and top incident causes
  • Single location for all claims and incident data
  • Incident-based design enabling incident-related KPI monitoring and streamlined claims filing
  • Easy report and graph generation to communicate or visualize KPI data

Cloud Claims makes it easy to choose which data to track and transfer into graphical representations so you can quickly spot trends and smoothly communicate KPI insights to your team.

Contact us today to schedule a Demo and experience Cloud Claims firsthand.

Your organization’s risk management information system (RMIS) collects and stores incident data, enabling efficient root cause analysis. It allows your company to make quick, informed decisions and take action to prevent future incidents.

While a scalable, customizable and intuitive RMIS can help your company manage risk effectively and reduce claim costs, a limited system can lead to inefficiencies and delayed decision-making — ultimately affecting risk mitigation. With that in mind, it is worth considering if your current RMIS meets your organization’s needs.

The following are signs that it is time to switch to a new risk management information system:

1. Limited Configuration Capabilities

Your industry has unique inherent risks and risk management requirements. Your RMIS should be flexible enough to adapt to your company’s needs, regardless of your industry. In other words, you should not have to adapt your processes to accommodate your RMIS. If your current RMIS does not allow customization, or if it is too difficult to customize anything within your RMIS, it is probably time to consider a more adaptable, easy-to-use alternative.

A configurable RMIS allows you to tailor forms, fields, templates, dashboards and reports to save employees time and help prevent inaccurate data entry. For example, you should be able to customize fields and drop-downs within an incident report to suit your organization and streamline form completion.

It is also worth considering a new RMIS if you do not own configuration capabilities and must work with a developer to make customized changes. Choose an RMIS that is configurable out of the box and save your company the cost of working with a developer.

2. Scalability Issues

As your business grows, your risk management needs will evolve. You may need to add new users to your RMIS, integrate with different systems or manage a greater data volume. Your RMIS should support your processes as your organization expands — not be an obstacle. If your RMIS struggles to process or store increased data or limits user access, it may be time for a change.

Similarly, if your current system does not enable you to attach files in various formats or upload claim documentation like incident-related photos or videos, it may be challenging to track and monitor a larger number of claims. Choosing an RMIS with unlimited data storage allows you to keep all of the key pieces of information needed for root cause analysis, no matter the size of your organization.

3.  Poor User Experience

User experience encompasses how your employees interact with your RMIS, as well as how they feel about it. A RMIS with a poorly designed interface, for example, can lead to user frustration or disengagement. By contrast, an intuitive, easy-to-navigate RMIS streamlines productivity, engages users and encourages them to use the system.

If management or other employees have avoided adopting your current RMIS, consider if your current system is user-friendly. Employees may not know how to use your RMIS or have found another, potentially inefficient, way to store and access risk management data. When considering a new RMIS, ensure it offers a positive user experience and is easy to navigate.

Your RMIS should smoothly integrate into your employees’ workflows and help them save time on claims and risk management processes. Employees should also feel confident when they log onto your system and understand how to use it quickly.

4. Inadequate Reporting and Analytics

One of the advantages of a well-rounded RMIS is being able to generate custom reports and utilize visualization tools, like graphs, to analyze data and make informed decisions quickly. It is worth evaluating your current system’s functionalities and considering if it has sufficient reporting and analytics tools to support your company’s goals.

In your evaluation, consider the quality of data you can access with your RMIS. If data, like claim codes, are outdated and challenging to modify, it may be difficult to generate accurate reports. Likewise, if you are unable to integrate with the insurance carrier and third-party administrator (TPA) systems, you may need to re-key financial data, increasing the chance of data entry errors and inaccurate reporting.

A solution would be to replace an outdated legacy system with new, comprehensive software that reduces the need for data re-entry.

5. Integration and Compatibility Issues

As mentioned above, if your current system requires employees to re-key information due to integration issues, you increase the chance of data entry errors and inaccurate reports. Accurate data is crucial to making decisions that will benefit your organization, such as deciding to implement a specific risk management technique.

It is also important that your RMIS promotes accurate and thorough data capture at the first notice of loss (FNOL). The key to accurate FNOL data is to quickly capture event details and enter the information directly into an RMIS. If your current RMIS lacks compatibility with other devices, it hinders the ability to input FNOL as soon as possible.

You can reduce data entry errors by choosing a cloud-based RMIS that seamlessly integrates with stakeholders’ systems and is mobile-device compatible. That way, claims adjusters can gather data at the site of the incident and enter it directly into your RMIS from their phone or tablet. With integration capabilities, stakeholders can easily access FNOL details and incident reports and respond promptly to the event.

6. Security and Compliance Concerns

A RMIS contains sensitive information, from personally identifiable information to company financial data. If you have any concerns about your system’s data security, it may be a sign you need a new RMIS. A data breach can harm an organization’s reputation and lead to regulatory fines and financial loss. According to IBM’s Cost of a Data Breach Report 2023, each data breach costs organizations an average of over $4 million.

A secure RMIS will protect your company’s data and ensure compliance with federal and state data protection laws. If you are searching for a new RMIS vendor, choose a vendor that can provide a SOC 2 Type II compliance report, as this demonstrates that its software has internal controls to adhere to privacy, security, processing integrity, confidentiality and data availability principles.

Consider Cloud Claims by APP Tech

A reliable RMIS that streamlines claim processing and helps your company identify and reduce risks can positively impact your bottom line and employee morale. If your current system no longer meets your organization’s needs, consider Cloud Claims.

Cloud Claim is our claims-focused risk management information system designed for self-insured businesses seeking comprehensive, user-friendly cloud-based software. Cloud Claims empowers organizations to promptly identify risks, take corrective actions and decrease claims costs.

With its incident-based architecture, Cloud Claims promotes accurate, streamlined data capture at FNOL. Users can customize FNOL fields and enter incident information, including uploading photos and videos, directly into their system from their mobile device — before there is even a claim. Cloud Claims allows you to:

  • Seamlessly integrate with TPA, insurance carriers, human resources and accounting systems.
  • Manage, track and process all claims within a single system.
  • Automate stakeholder communications and employee workflows.
  • Generate customizable and ready-to-go reports to gain insights and comply with regulations.
  • Easily scale as your company grows.
  • Feel confident about data security and compliance with Soc 2 Type II certification.
  • Access tailored onboarding for quick deployment and a 100 percent successful implementation rate.

Contact us today to learn more about Cloud Claims or request a demo.

Claims management can be a complex and time-consuming process rife with challenges, from ensuring claim data integrity to maintaining contact with claimants. In addition, self-insured organizations and third-party administrators (TPAs) are under significant pressure to process claims as quickly as possible.

Regardless of an organization’s current position, streamlining the claims management process is achievable. Purpose-built technology, like customizable claims management software, helps organizations implement strategies to resolve claims faster, mitigate and prevent repeat incidents, and keep key stakeholders informed.

8 Effective Claims Management Strategies

Claims management strategies aim to maximize efficiency, mitigate risks and eliminate unnecessary steps, ultimately reducing costs and improving stakeholder satisfaction. The following strategies can help your organization improve workflows and accomplish these objectives.

1. Enter Accurate Data at the First Notice of Loss

Entering data into your system accurately with the First Notice of Loss (FNOL) is crucial to preventing settlement delays and promoting claimant satisfaction. Claim adjusters can leverage technology to simplify accurate data collection.

For instance, once an employee submits an FNOL report, an adjuster can use mobile-compatible claims management software to gather data at the incident site. They can take photos and videos, collect witness contact information and document environmental conditions, all while entering this information into their organization’s system via their mobile device. This capability reduces the need to manually enter FNOL data later, preventing redundancy and decreasing the risk of error.

Depending on your organization’s structure, you might also give employees access to a mobile app that integrates with your system so they can directly enter FNOL data immediately following an incident — while the details are still fresh in their minds.

2. Simplify Incident Reporting

Removing barriers to reporting is essential to identifying risks and resolving issues, like workplace safety challenges, before they become greater problems. It also puts the claims process in motion and ensures deadlines are met.

For example, prompt reporting is integral to being able to initiate post-incident drug testing and determine if substance use contributed to the incident. Depending on your state’s workers’ compensation laws, a failed drug test could impact the employee’s claim, potentially saving your organization from related costs.

With an intuitive, customizable system, you can make it easy for adjusters to report incidents and document details quickly and accurately. Claims management software with customization capabilities allows you to preset fields and forms, some of which may populate automatically, and prompt adjusters to add information that aligns with your organization’s reporting policies. With a tailored system, adjusters do not have to question what data to enter to follow the relevant policy. Instead, they can enter data quickly and feel confident in their process. Fields that automatically populate can help reduce errors as well.

Choosing software that tracks deadlines and alerts users if information is missing also provides an advantage, allowing you to ensure adjusters have added the necessary details before settlement or litigation activities.

3. Maintain Clear Communication With Key Stakeholders

Keep communications clear with key stakeholders, like TPAs, managers, claimants and service providers, to encourage smooth claim processing and prevent delays. Your system plays a major role in achieving timely communication and keeping stakeholders informed.

For example, a claim management system can alert managers or supervisors in real time when an incident occurs, allowing them to take action and address the cause of the incident quickly. It can also integrate with a partner’s systems to simplify communications and ensure everyone is on the same page.

You can use claims management software to communicate with claimants and keep them informed on the status of their claims. Some claimants may prefer digital notifications over speaking to an adjuster on the phone, so your technology can help make the process less stressful.

4. Streamline Claims Processing With Integration

Consider how integration with other systems, partners and vendors can help with data integrity and reduce manual data entry and analysis. For example, for claims involving employees, keeping accurate contact information, safety certifications and pay rates can help expedite the claim. For claims involving property or assets, integration with your current systems to track property can help with tracking inventory and recovery efforts.

Many organizations enlist the assistance of vendors such as medical bill review providers or TPAs to help process their claims. Claims management software can integrate directly with these types of external systems to minimize the burden and errors of data re-entry and consolidate your data for easy and accurate analysis and reporting.

5. Ensure Your Claims Management System Aligns With Your Policy

Your claims management system must align with your policy so adjusters can make informed decisions quickly and easily. It should also ensure payments are disbursed according to your policy’s coverage limits.

Ideally, you will be able to configure your software to reflect your policy’s limits. Your system should track payments, automatically adjust balances and notify adjusters of impending deadlines so they can act promptly and ensure providers are paid and settlements are reached in a timely manner.

6. Simplify Processing With Automated Tasks and Tracking

If team members do not know who is responsible for processing a claim or completing a task, the claim may sit in a queue longer than it should. You can help prevent stalled claims with the power of automation.

Use claims management software that automatically assigns tasks to the appropriate adjuster. Set task reminders and notifications to ensure adjusters meet critical deadlines. Lastly, the system should track assigned tasks to monitor the progress of a claim so you can keep stakeholders updated or investigate and address delays.

7. Take an Incident-Based Approach

Today’s self-insured organizations prioritize preventing incidents and claims from happening in the first place. An incident-based approach to claims processing helps these entities achieve risk management goals while streamlining workflows.

Incident-based claims management revolves around real-time incident reporting, reducing manual data entry and incorporating risk management. Accurately capturing incident details is critical to minimizing the chance of recurrence. An incident-based approach empowers self-insured companies to find patterns and avoid repeat incidents, cutting costs and protecting employee morale.

Incident-based claims management software allows adjusters to log incidents, such as work-related injuries or property damage, even in the absence of a claim. Stakeholders like regional managers can set the system to provide immediate notification so they can take corrective action and prevent additional incidents.

Adjusters can also use an incident-based system to enter data for multiple claims that arise from the same incident. This feature reduces duplicate content and minimizes error.

With a comprehensive, incident-based claims management solution, all documentation related to an incident is digitized and centralized for easy access. For instance, a company’s risk managers can access the software and learn about incidents at one location to prevent them from occurring elsewhere.

8. Adopt Flexible Claims Management Software

Self-insured companies no longer need to conform their workflows to rigid structures or preset fields. Instead, they can adopt configurable claims management software to support their unique needs.

Customizable software allows your company to tailor workflows to suit your processes and automate tasks to remove time-consuming manual work. With a flexible solution, you can customize the user interface to simplify navigation and boost adjuster engagement, efficiency and satisfaction. An adaptable system also scales with your business as you grow and can handle large volumes of claims when needed.

Streamline Your Entire Workflow With Cloud Claims

Although claims processing is complex, the right technology can help you implement effective strategies that simplify the process. By leveraging technological tools, your organization can optimize workflows, stay compliant and process claims efficiently, ultimately improving your bottom line.

At APP Tech, we support this goal by offering Cloud Claims — a flexible, incident-based claims management solution designed to streamline and track claim activities. We tailor Cloud Claims to fit your organization’s unique workflows and provide features and benefits including:

  • Automated notifications
  • Customizable dashboard, templates, fields and drop-downs
  • Desktop, tablet and mobile device compatibility
  • Unlimited storage for claim documents such as PDFs, photos and videos
  • Access to support teams that understand MMSEA Section 111 compliance

Request a Demo to explore Cloud Claims, or visit our blog to discover more tips for a smoother claim management process.

Outdated software can pose many risks for businesses that rely on accurate data and efficient processes. Systems that do not keep up with changing technologies inhibit smooth operations and create inefficient workflows. Replacing a claims management system that may already be obsolete creates more opportunities for agile processes in your business. It minimizes work disruption, adapts to organizational needs and may increase overall efficiency.

Assessing your company’s needs before replacing your legacy system is vital to choosing the right one. A smooth transition between a legacy system and a new one requires planning and careful execution.

Assess the Need to Replace Your Claims Management System

Start by identifying the shortcomings you see in your current claims management system. Essential elements of a well-functioning system include scalability with your business, no redundant data entry, an easy-to-use interface, quality reporting, and compliance with internal policies and external regulatory requirements.

During this assessment, it is important to note that “legacy” only sometimes refers to older systems. The risks of a legacy system can relate to any claims management system that does not fulfill its requirements. Risks of using legacy systems include:

  • Performance concerns: Legacy software may require more manual input, like re-keying data from other system, which demands additional human resources. This diverts employees’ focus from important tasks to troubleshoot software issues.
  • Documentation control: Many legacy systems do not track claim documentation (e.g. photos, emails, and notes) internally, relying on external shared drives or email. This create inefficiencies and can lead to poor decisions due to missing information.
  • Compatibility issues: Given the monolithic architecture of legacy software, updates can cause system conflicts or may not be available. Additionally, legacy software might not be compatible with new application programming interfaces (APIs), impeding integration.
  • Poor security: Older systems run a higher risk for security breaches, such as the 70 percent of health care systems that fell victim to a cyber attack in 2018.

Plan to Replace Claims Management Software

Determine which functions will most complement your business operations. Improving workflow, employee satisfaction and stakeholder insight is paramount, so reach out to your team to establish what functions will make a difference day-to-day. Include these additional measurements to plan for an optimal replacement:

  • Find the right partner: Select a reputable software provider to ensure you get a high quality claims management system. An additional feature to look out for is unlimited tech support, which will simplify the implementation and maintenance processes.
  • Budget: The initial cost of a new system may be high, especially if your current system is particularly outdated. Ask your intended service provider for an accurate cost estimate to help with your planning.
  • Plan employee training: Include training in your budget for updating claims management systems. This will prevent productivity loss and minimize errors during the beginning stages of getting acquainted with your software.
  • Data migration: If you need to migrate data from the legacy system into the new one, ensure that the software you are considering will be able to handle the volume and complexity of data you plan to transfer.
  • Maintenance and support: As you consider different vendors, assess the level of support they provide during and after sales. It is especially important to note their availability for ongoing maintenance, troubleshooting and software updates.

Choose the Right Claims Management Software

Once you plan to acquire a new claims management system, you need to define the features your team needs from the new system. While each industry’s needs will differ, some general characteristics that ensure success are:

  • Scalability: Ensure the new system will scale with your business growth and the integration process will be simple.
  • Cost analysis: In addition to a budget for upfront costs, consider ongoing system expenses. Maintenance, support and upgrades may incur additional overhead. Calculate the total cost of ownership for the system you are interested in.
  • User-friendliness: A claims management system should be intuitive to help your team adapt without extensive training or prolonged downtime.
  • Real-time data and reporting: Real-time insight into the status of claims will offer quick turnaround times and bypass any bottlenecks. These benefits will affect customer satisfaction, boosting your business reputation.
  • Customization: A flexible system that allows customization according to your needs enhances operational efficiency. These systems will also easily accommodate future changes and growing digital requirements from your industry.
  • Compliance and security: The new system should help your operations meet security standards and compliance regulations. Claims data often contain personally identifiable information (PII) and protected health information (PHI), so making sure your vendor has a SOC 2 certification (or similar) will give you confidence that the system you will rely on is secure.

Create a Smooth Transition

Replacing your legacy claims management system requires meticulous steps to ensure you do not lose any data in the system. It takes careful planning, clear communication and adequate training to transition smoothly when updating claims management software. Follow these steps to create a smooth migration to your new system:

  • Transition plan: Detail the transition plan, outlining goals, timelines, key milestones and specific roles and responsibilities of various stakeholders.
  • Training: Schedule training sessions for everyone using the new claims management system. Ensure that this training helps them understand new features, functionalities and workflow changes. Create online tutorials and guides for employees to reference when they need to. You can also ask your provider about demo systems for training sessions.
  • Data assessment: Evaluate the data in your legacy system. Create a strategy to migrate that data to the new system that maintains accuracy and integrity. Working with a project manager from your team or service provider throughout this process is helpful.
  • Implement in phases: Consider implementing your new system in stages. This allows for gradual adaptation, minimizing the migration’s impact on daily operations.
  • Open communications: Remain consistent and transparent in your communication with stakeholders during this transition. Ensure everyone is up-to-date on changes, progress and timelines.
  • Evaluation: Gather feedback from stakeholders and conduct post-implementation reviews once the system is in place and used daily. Evaluations allow you to address challenges with your service provider and identify areas with room for improvement.

Replace Your Claims Management System With Cloud Claims

Familiar, legacy systems may have a comfort in them for stakeholders but ignoring business growth, security and efficiency will create big costs down the line. An agile claims management system will ensure you have accurate documentation and open up opportunities to reduce risk and control claims costs, no matter what industry you’re in.

APP Tech understands your business’s pressing needs in its claims management processes. Our claims management systems cater to complex and diverse portfolios with ease. Cloud Claims streamlines processing, prevents data duplication and offers user-friendly reporting. Learn more about this system and contact APP Tech for more information about how you can seamlessly transition into your new claims management system.

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