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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As a business owner, it is important to examine potential commercial risks and implement strategies to deal with them. One efficient approach is purchasing insurance. However, for some businesses, traditional insurance is too expensive or generally incapable of meeting their needs. As a result, self-insurance has become an attractive alternative.

But what is self-insurance all about? How does it even work? Are there specific types of coverages for self-insured businesses? How can you manage your claims effectively? This self-insurance guide addresses all these concerns.

What Is Self-Insurance?

Self-insurance is an alternative to purchasing traditional, “dollar one” insurance, where businesses set aside money to pay for possible losses. As opposed to traditional insurance, which involves a third-party insurance provider, the business incurs the costs for accidents, medical bills, thefts, lawsuits and so on from their own pockets.

There are many reasons for self-insuring your business. For example, you can save money you would otherwise spend on insurance premiums and invest it in other parts of your business. It allows you to set money aside to cater to perils as they arise, thereby preventing overpayment. Additionally, depending on how you manage the savings, it can yield interest, especially when you have infrequent losses. Self-insurance also gives you tailored coverage since you can create an insurance plan that favors your business needs.

While enjoying all these benefits, self-insured businesses must comply with all relevant federal and state insurance regulations. For example, although business owners have the freedom to plan their insurance, certain coverages like workers’ compensation, unemployment and disability insurance are mandatory.

One significant challenge self-insurers face is claims management, especially when there are large volumes of data. The good news is that you can use advanced cloud-based tools to simplify your claims management. Incident-based cloud management technology facilitates data-driven insights, provides audit capabilities and custom reporting and generally streamlines every aspect of self-insurance claims management.

How Does Self-Insurance Work?

Self-insured businesses assess potential risks and set aside money to cover expenses, if those events occur. When someone files a claim, the company pays directly from its own funds. The employer may create a dedicated team to monitor and process claims or hire the services of a third-party administrator (TPA) to handle all things claims related. Alternatively, the business can manage some parts of the self-insurance program and reserve other functions for a TPA.

The dedicated staff or TPA will calculate the amount to set aside, considering your insurance needs, potential risks, and the expected claims that could arise. Anticipating these challenges and potential costs will determine your risk tolerance.

For example, if your business has a high chance of encountering lawsuits — as in the case of product defects, professional liability or personal injuries — you will set aside money for indemnity settlements plus expenses like attorney fees and court expenses. If your business collects, stores and uses large volumes of customer data, reserving money for potential data breaches and the costs to resolve them will be required.

After weighing out the possibilities of losses, the business will determine what its self-insured retention (SIR) should be. Although a business is “self-insured,” it is unlikely to be self-insured to unlimited liability. The self-insured retention is the amount of money a business covers itself, before the excess / stop-loss coverage kicks in. Limits are typically set on a per-occurrence basis and on an aggregate basis. The higher the retention, the lower the insurance premiums will be, but the more risk the business bears in the event of a loss. Once the self-insured retention limits are reached, an insurance carrier will cover costs, limiting liability to the business.

Whether you develop an internal self-insurance team, partner with a TPA or leverage the advantages of both, using a cloud management software to manage claims within the self-insured retention is recommended. An incident-based self-insurance claims management technology combines data from internal and external sources in a system, giving you a single source of truth.

What Does Self-Insurance Cover?

Four common self-insurance coverages for businesses are

  1. General liability insurance: Business or general liability insurance covers claims during normal business operations, like slips and falls and property damage. The coverage may change depending on the nature of the business you operate.
  2. Property insurance: Self-insured businesses may set aside money for damages to commercial assets, like buildings, inventory and equipment. Potential risks include theft, fire and flood damage.
  3. Auto insurance: Auto or vehicle insurance is necessary for businesses that own commercial vehicles, like vans and trucks. The coverage may pay for property damage and injuries if an employee causes an accident.
  4. Workers’ compensation insurance: Insurance covering job-related injuries to employees. Rules vary significantly by state.

How Is Self-Insurance Different From Traditional Insurance?

The obvious difference between self-insurance and traditional insurance is the absence of a third-party provider. This means, for all claims up to your self-insured limit, you need to do everything the third-party insurance provider would do yourself or with the assistance of a TPA. Instead of purchasing full coverage from an insurance company, the business saves cash and creates a reserve for covering potential losses. The business owner uses an internal insurance team or TPA to determine how much would be enough to cover the losses. For example, in the case of workers’ compensation, the company acts as the employer and insurance provider to the employees and generally bears the potential liabilities that would otherwise be covered by an insurance carrier.

Are There Any Requirements for Self-Insurance?

Self-insured businesses should meet the following requirements:

  • Legal compliance: The company must comply with all relevant insurance laws and regulations, considering the mandatory coverages.
  • Financial stability: Self-insured businesses should be financially stable and capable of covering expenses that arise.
  • Risk assessment: The employer should have a team for comprehensive risk assessments and mitigation.
  • Administration: It is best to have claims management systems to streamline insurance administration.

The specific requirements will vary by state and by the type of coverage being self-insured. Workers’ compensation has far more regulatory requirements than property insurance. Therefore, it is common for business to self-insure certain types of losses (e.g. property) and maintain traditional insurance for others (e.g. workers’ compensation).

How Do You Become Self-Insured?

Here are five ways you can manage self-insurance:

1. Create a Strong Team

Whether you establish an internal insurance and risk assessment team or choose a TPA, ensure the team is well-positioned to provide the required service. The insurance professionals should understand your business needs and offer clear plans to deliver results. Additionally, the team should ensure compliance with federal and state laws.

2. Do a Comprehensive Cash Flow Analysis

Self-insurance is only possible if you have sufficient funds to cover losses. Therefore, it’s vital to do a comprehensive financial analysis to understand your financial situation and insurance needs. This would help you determine how much loss you can cover and set limits that don’t endanger the health of the business.

3. Develop a Self-Insurance Policy

Develop a policy or guideline that covers eligibility, exclusions, benefit coverages, policy limits, and cost-sharing. Weigh the advantages of the self-insured plan, such as the lower cost coverage and flexibility against administrative responsibilities and increased risks. This will help you know whether the plan is effective and worth pursuing.

4. Get Stop-Loss Insurance Coverage

Stop-loss insurance is the coverage that reimburses self-insured businesses for high claims or those that exceed the self-insured retention’s limits. The employer sets a claim limit, above which the claims carrier will cater to the difference. It is like insuring your insurance. The arrangement helps businesses address unexpected risks.

5. Use Claims Management Software

Incident-based claims management solutions designed for self-insured businesses have many benefits. They enable you to learn from every incident and identify the root cause of accidents. That way, you can adequately assess the risks and implement strategies to reduce them. Leveraging these advanced solutions saves money and ensures you are maximizing savings for your self-insured program.

APP Tech — Claims Management Software for Self-Insured Businesses

Self-insured businesses assume the company’s potential risks instead of relying on third-party insurers for coverage. This saves money and allows the business to create a tailored plan according to its needs. While managing self-insured companies can be complex, cloud management software makes claims processing simple and efficient.

APP Tech’s Cloud Claims is an advanced incident-based system that provides end-to-end cloud solutions for your claims management. It enables you to analyze losses, track claims and policies, and track all your finances. Cloud Claims is also customizable. If you want to learn more about how to streamline your claims management processes, contact us now!

Discover the various claim management trends from the field that self-insured businesses, third-party administrators (TPAs) and insurance solution providers must know. Staying up-to-date with the current trends in claim management will position your organization for success. In 2023, as claims processing continues evolving, we unveil the pivotal claims processing trends that will shape your strategies.

From streamlining operations to harnessing advanced technologies, this guide will list and explain the top trends in claim processing in 2023 that shape efficient and forward-thinking claim management practices.

Claim Management Trends in 2023

Let’s dive into current trends in claim management and explore the transformative claims processing trends driving innovation and efficiency.

1. Incident-Based Approach — Redefining Claims Management

Amid claim management trends in 2023, one trend stands out — the incident-based approach. Departing from traditional methods, this approach revolves around real-time incident reporting. By promptly ingesting data for informed decision-making, businesses ensure accuracy and relevance.

Cloud Claims, a sophisticated solution for incident-based processing, bolstered this transition. With the ability to swiftly report incidents through smartphones, complete with attached visuals, Cloud Claims pioneers a seamless shift toward efficiency and precision. As businesses embrace this trend, they redefine their claim management landscape, setting the stage for enhanced operational agility and optimal outcomes.

2. Expedited Data Ingestion and Prompt Decision-Making

Timely and accurate data is the foundation for efficient claims processing and technology plays a pivotal role. Harnessing innovative tools, stakeholders can swiftly ingest data, triggering real-time alerts that keep all parties informed. This accelerated flow enables agile decision-making, transforming claims into actionable insights.

By adopting configurable systems tailored to individual client needs, businesses cultivate an environment where prompt, well-informed decisions become the norm. In the claims industry, the ability to expedite data flows and facilitate rapid decisions propels organizations toward operational excellence and heightened stakeholder satisfaction.

3. Configurable Systems — Adapting to Unique Client Needs

In 2023, claim management is shifting toward adaptable and client-centric systems. Every organization operates with its distinct processes, workflows and requirements. Configurable systems offer the flexibility to mold claim management tools according to these individual needs. This trend ensures that businesses no longer conform to rigid, pre-set structures but can instead design seamless workflows that align with their operations.

Cloud Claims offers a purpose-built incident-based claims management system tailored to the intricate demands of self-insured entities, TPAs and insurance providers. This adaptable approach streamlines claims processing and maximizes efficiency, accuracy and client satisfaction. As the industry utilizes this trend, businesses can expect enhanced control, improved outcomes and a competitive edge in claim management.

4. Bridging the Gap — Self-Insured Corporates and Big Insurers

Self-insured entities are no longer confined to antiquated systems or limited by technological constraints. This trend acknowledges the importance of equipping self-insured corporates with the same advanced claims processing capabilities that big insurers have long enjoyed. Cloud Claims plays a pivotal role by offering purpose-built technology tailored to the unique needs of self-insured businesses.

By adopting this trend, organizations can surpass the limitations of email chains, spreadsheets and outdated systems. Cloud Claims empowers self-insured corporates to harness efficient claims handling, data-driven insights and streamlined processes like those of established insurers. This trend ensures that self-insured entities can compete on a level playing field, achieve substantial cost savings and optimize their claims management practices for success.

5. Real-Time Insight and Stakeholder Participation

Looking further into claim management trends, real-time insight and stakeholder participation emerge as central catalysts of efficient and proactive claims processing. This trend redefines the role of corporate stakeholders, enabling them to actively improve safety and reduce loss.

Cloud Claims enable real-time insights, providing stakeholders with a comprehensive view of organizational activities. Stakeholders can make informed decisions, monitor trends and contribute to risk mitigation strategies by actively participating in the claims management process. Real-time insight and stakeholder participation enhance claims processing and foster collaboration, transparency and accountability.

Trusting APP Tech for Incident-Based Claim Management

When it comes to claim management trends, staying ahead is crucial. As insurance solution providers seek effective strategies for 2023, key claim management trends shape these strategies and facilitate informed decision-making. The incident-based approach innovates claims management, while real-time insights and configurable systems expedite decisions.

APP Tech’s Cloud Claims seamlessly blends cutting-edge features with a user-friendly design. By bridging the gap between self-insured corporates and industry giants, Cloud Claims ensures efficient claims processing akin to big insurers. As you navigate these current trends in claim management, remember — Cloud Claims is not just software, it is a partner in simplifying complexity.

Request a Demo today and learn more about incident-based claim management.

As a business exploring avenues to optimize risk management, the concept of self-insurance presents a compelling opportunity. Self-insurance can result in greater control of your claims and cost savings, but this comes with additional responsibilities. In this post, we’ll review the essential considerations for businesses contemplating self-insurance.

Among these considerations, we highlight the significance of robust claim management solutions for self-insured businesses. Discover how leveraging advanced technologies can streamline claims handling, enhance risk management and unlock the potential benefits of self-insurance tailored to your specific needs.

Should your company consider self-insurance? Let’s find out.

The Pros and Cons of Self-Insurance

When considering self-insurance, companies must carefully weigh the advantages and disadvantages. Here are the key pros and cons.

Pros of Self-Insurance

Discover the advantages that make self-insurance an enticing option for businesses:

  • Cost savings and control: Self-insured companies have the potential to save on insurance premiums by eliminating the profit margin of traditional insurers. Additionally, they retain control over risk management strategies and claim payouts.
  • Tailored coverage: Self-insurance allows customized insurance plans to match specific risk profiles and business needs, ensuring comprehensive coverage where it matters most.
  • Investment opportunities: Instead of paying premiums to external insurers, self-insured businesses can invest these funds, potentially yielding returns that contribute to financial stability.
  • Long-term stability: With stable claim experience and risk management practices, self-insurance can offer more predictable and consistent costs over time.

Cons of Self-Insurance

Carefully consider the potential drawbacks and challenges associated with self-insurance to make well-informed decisions:

  • Financial exposure: Self-insured businesses are directly liable for claims, which can pose significant financial risks in case of large or catastrophic losses.
  • Cash flow management: Setting aside reserves for potential claims requires effective cash flow management and financial planning.
  • Regulatory compliance: Self-insured firms must comply with state regulations and requirements, necessitating diligent adherence to legal obligations.
  • Administrative burden: Managing claims and risk internally demands dedicated resources and expertise, potentially increasing administrative complexities.

10 Important Business Considerations for Self-Insurance

Before deciding to go self-insured, businesses must carefully analyze critical factors that impact their risk management strategy. These considerations ensure a comprehensive evaluation of the feasibility and suitability of self-insurance for your company’s unique needs. Self-insurance is not an all-or-nothing proposition. It may make sense to self-insure certain types of losses and conventionally insure others.

1. Risk Analysis and Assessment

Conducting a thorough risk analysis and assessment is the foundational step in considering self-insurance. Businesses must identify and evaluate potential risks, assess their frequency and severity and determine the financial implications of self-insuring against these risks. Understanding the unique risk profile of your business enables informed decision-making and effective risk management strategies.

A comprehensive risk analysis will ensure that self-insurance aligns with your company’s risk tolerance and long-term financial goals — providing the groundwork for a successful self-insurance program.

2. Financial Stability and Reserves

Financial stability is paramount for businesses considering self-insurance. Adequate reserves are essential to cover potential claims and minimize financial risks. Companies must assess their cash flow capacity to set aside resources and ensure they have sufficient funds to handle unexpected losses. Understanding the balance between risk retention and financial preparedness is critical.

Establishing a well-structured reserve fund will provide the necessary safety net and financial security, enabling the self-insured company to navigate various claim scenarios and maintain smooth operations in the face of potential challenges.

3. Regulatory Compliance

Navigating the regulatory landscape is crucial when considering self-insurance. Firms must thoroughly understand their jurisdiction’s legal requirements and obligations associated with self-insurance. Compliance with state regulations, reporting mandates and financial solvency standards is essential to avoid potential penalties and legal issues.

Partnering with experts or third-party administrators can help ensure adherence to all regulatory requirements and streamline compliance. Prioritizing regulatory compliance allows businesses to confidently embrace self-insurance while maintaining a solid reputation and standing within the industry.

4. Employee Communication and Engagement

Effective employee communication and engagement are integral to the success of self-insurance. Businesses must transparently communicate the transition to self-insurance, addressing concerns and providing clear information about the benefits and impact on employees’ coverage.

Engaging employees in the process fosters a sense of ownership and responsibility, encouraging them to be more conscious of risk management practices and claim prevention. Regular communication channels and educational resources can empower employees to participate actively in the self-insurance program — ultimately contributing to a safer work environment and better overall risk management outcomes.

5. Stop-Loss Insurance

When considering self-insurance, companies should also evaluate the option of obtaining stop-loss insurance. This essential safety net protects against catastrophic or high-cost claims that exceed predetermined thresholds. By purchasing stop-loss insurance, businesses can mitigate the financial risks associated with large claims, ensuring they don’t face overwhelming financial burdens.

Evaluating different stop-loss insurance options and understanding the coverage limits is crucial to balance self-insurance and external risk protection — allowing businesses to confidently self-insure while safeguarding against extraordinary claim scenarios.

6. Data and Analytics

Data and analytics play a pivotal role in the success of self-insurance. Companies must leverage advanced technologies and data-driven insights to make informed decisions about risk management strategies. Utilizing comprehensive data analytics enables businesses to identify trends, assess claim patterns and implement proactive measures for risk prevention.

Access to real-time analytics empowers businesses to refine their self-insurance program and optimize claims management processes continuously. By prioritizing data-driven decision-making, companies can enhance overall risk management efficacy, resulting in cost savings, improved claims handling and better risk mitigation outcomes.

7. Employee Wellness and Risk Mitigation

When self-insuring worker’s compensation losses, employee wellness and risk mitigation are crucial components of a successful self-insurance program. Businesses should prioritize promoting a culture of safety and wellness to reduce the frequency of workplace incidents and claims. Implementing robust safety protocols, employee training and wellness initiatives may significantly reduce risk.

By proactively addressing employee well-being, businesses can minimize the occurrence of claims and create a safer work environment. Integrating employee wellness and risk mitigation strategies with self-insurance helps optimize the program’s overall effectiveness and enhances the company’s ability to manage risks efficiently.

8. Long-Term Commitment

Choosing self-insurance is a long-term commitment that requires careful consideration. Firms should evaluate their ability to maintain financial stability, risk management practices and employee engagement over an extended period. Self-insurance is not a short-term solution but a strategic decision with lasting implications.

Businesses must prepare to invest in ongoing risk analysis, claim management solutions for self-insured companies and employee wellness initiatives. Assessing the company’s long-term objectives and risk appetite is crucial to ensure that self-insurance aligns with the organization’s overall vision and goals for sustained success.

9. External Expertise

Seeking external expertise is invaluable for businesses considering self-insurance. Companies can collaborate with experienced consultants, insurance brokers or third-party administrators (TPAs) to navigate the complexities of self-insurance effectively. These experts can provide invaluable insights and guidance on regulatory compliance and help design tailored self-insurance programs that align with the company’s risk profile and financial goals.

Leveraging external expertise streamlines the self-insurance implementation process. It ensures businesses have access to the knowledge and resources necessary to optimize risk management strategies, claim handling and overall success in their self-insurance journey.

10. Claim Management Capability

A robust claim management solution is essential for successful self-insurance. Businesses can invest in advanced claim management solutions — like APP Tech’s Cloud Claims — to handle and process claims efficiently. These purpose-built technologies streamline incident-based claims management, automate notifications and offer user-friendly dashboards for at-a-glance views of claims.

With features like document organization, audit capabilities and custom reporting, businesses gain transparency, data-driven insights and effective risk management. This ensures businesses can confidently embrace self-insurance with comprehensive claim management support.

If managing a self-insurance program in-house isn’t feasible, contracting the services of a third-party administrator (TPA) can fill that gap. In this case, making sure the TPA has robust claim management software should be an important consideration when choosing the TPA. In cases where you are self-managing some parts of your self-insurance program but letting a TPA manage other parts, having the ability to combine data from internal and external sources in a system like Cloud Claims means you have a single source of truth for all your loss data.

Empower Your Self-Insurance Journey With APP Tech’s Cloud Claims

Empower Your Self-Insurance Journey With APP Tech's Cloud Claims

As you consider if your company should consider self-insurance, remember the vital considerations that guide this strategic decision. Evaluating risk analysis, financial stability, regulatory compliance and employee engagement is paramount. Additionally, for businesses considering self-insurance, navigating claim management challenges is inevitable. That’s where comprehensive claim management software for self-insured businesses becomes invaluable.

Take charge of your risk management future — schedule a tailored Demo today and experience the efficiency of Cloud Claims.

 

Having a comprehensive understanding of the Centers for Medicare and Medicaid Services (CMS) is crucial for stakeholders across a range of industries, from health care providers to liability and worker’s compensation insurers. Self-insured entities, third-party administrators (TPAs) and insurance solution providers need to navigate the CMS landscape to ensure compliance, streamline operations and mitigate risks.

But what is the Centers for Medicare and Medicaid Services? Simply put, CMS is the federal agency that administers the Medicare and Medicaid programs. These programs provide health care services and coverage to millions of Americans. As a result, the CMS plays a pivotal role in the United States health care system.

In this post, we’ll explore how CMS works and the different programs CMS oversees. We will also provide an introduction to the complex world of Mandatory Second Payer and MMSEA Section 111 reporting compliance.

Roles and Responsibilities of CMS

CMS plays a vital role in administering the Medicare and Medicaid programs and ensuring access to health care coverage for different populations. CMS sets guidelines and regulations to govern these programs, fostering compliance and facilitating health care services.

Regulating and overseeing health care providers participating in Medicare and Medicaid is a primary responsibility of CMS. This involves establishing standards for provider enrollment, care quality and patient safety, and conducting surveys, audits and inspections to monitor compliance.

CMS also manages payment and reimbursement systems, establishing fee schedules, rates and payment methodologies. It strives for fair and accurate payment to providers while controlling costs and preventing fraud and abuse.

To improve health care delivery, CMS implements various initiatives and programs. It promotes evidence-based guidelines, fosters innovation and incentivizes value-based care models to enhance quality.

CMS prioritizes fraud prevention and enforcement. Sophisticated data analytics, audits, investigations and enforcement actions are employed to combat fraud, waste and abuse of taxpayer funds.

CMS collaborates closely with state governments, stakeholders and industry experts. It partners with states to administer Medicaid programs and fosters information exchange and collaboration for innovation and improved health care outcomes.

By fulfilling its roles and responsibilities, CMS ensures effective administration, regulation, and oversight of Medicare and Medicaid. This empowers self-insured entities and insurance solution providers to navigate complexities while delivering high-quality care to their claimants and beneficiaries.

Understanding CMS Programs

Medicare and Medicaid are the two programs administered by CMS. Let’s explore their significance in the health care landscape.

Medicare Program

Medicare serves as a lifeline for eligible individuals, providing essential health care coverage based on specific criteria. To qualify for Medicare, individuals must generally be aged 65 or older, but it also covers certain individuals with disabilities or end-stage renal disease.

Medicare consists of different parts, each offering specific coverage and services:

  • Part A: Part of traditional Medicare, Part A includes hospital insurance and covers in-patient hospital stays, hospice care, skilled nursing facility care and limited home health care services.
  • Part B: Part B is also part of traditional Medicare, and includes medical insurance and covers out-patient services, including doctor visits, preventive care, certain diagnostic tests and durable medical equipment.
  • Part C: Created in 1997, Part C is part of Medicare Advantage and offers an alternative to the original Medicare, providing all-in-one coverage through private insurance plans approved by Medicare. Medicare Advantage plans often include prescription drug coverage (see Part D below) and additional benefits like dental and vision care.
  • Part D: Part D, added in 2003, also forms part of Medicare Advantage and provides prescription drug coverage and helps individuals pay for prescription medications, offering a range of prescription drug plans.

Medicaid Program

Medicaid serves individuals and families with limited financial resources, offering access to essential health care services. Eligibility for Medicaid is based on income and other specific criteria, which vary from state to state. The program aims to ensure that vulnerable populations, including children, pregnant women, individuals with disabilities and the elderly, have access to comprehensive health care coverage.

In recent years, Medicaid expansion has been a significant development. Under the Affordable Care Act (ACA), states have the option to expand Medicaid eligibility to cover individuals with higher income thresholds. This expansion has extended coverage to millions of additional individuals who were previously uninsured.

Medicaid provides a broad range of covered services, including, but not limited to, hospital visits, doctor appointments, preventive care, prescription medications and mental health services. The program aims to address the health care needs of low-income populations and improve their overall well-being.

Children’s Health Insurance Program (CHIP)

Medicaid Expansion CHIP, established in 1997, is designed to fill the gap for children who do not qualify for Medicaid but still lack access to affordable private health insurance. The program ensures that eligible children have access to comprehensive health care services, including doctor visits, immunizations, hospital care and prescription medications.

Eligibility for CHIP varies by state, but generally, children in families with income levels above the Medicaid threshold can qualify. CHIP provides coverage to millions of children, ensuring their well-being and providing necessary medical support.

From preventive care to specialized treatments, CHIP covers a broad range of health care services to meet the unique needs of children, promoting their healthy growth and development.

Medicare Secondary Payer (MSP)

Medicare Secondary Payer (MSP) provisions were established in 1980 to shift payment responsibility away from Medicare, in response to concerns over the long-term financial health of the Medicare program. Initially, Medicare was designed to be the primary payer for health care services for eligible individuals aged 65 and older. However, as the program evolved, policymakers recognized the need to prevent Medicare from bearing the full burden of health care costs when other coverage options were available.

MSP refers to a set of rules and provisions established by the U.S. government to determine the order of payment when an individual has health care or injury coverage from multiple sources. The primary goal of MSP is to ensure that Medicare is not the primary payer when other sources of coverage exist. Under the MSP rules, Medicare acts as the secondary payer in situations where another entity, such as an employer group health plan, workers’ compensation, or liability insurance has the primary responsibility for covering health care costs. The primary payer must fulfill its obligations before Medicare pays for any remaining expenses.

In cases where another payer may be responsible, Medicare will make payments for health care services conditionally, known as Conditional Payments. These payments must be repaid to Medicare if a settlement, judgement, or award is made to the Medicare beneficiary in compensation for the injuries.

Additionally, MSP requires claim settlements involving Medicare beneficiaries to take Medicare’s future interests into account. This is done through Medicare Set-Asides (MSAs) arrangements, which reserve funds (i.e. “set them aside”) from a settlement to be used by Medicare to cover future medical expenses.

MSP rules help prevent unnecessary expenditures and preserve Medicare’s financial resources. They require individuals and health care providers to report any other sources of coverage to Medicare, ensuring that the program does not pay for services that should be covered by another entity.

With conditional payments, set-asides, and the many other tools in Medicare’s toolbox, complying with MSP regulations can be challenging, but it is absolutely necessary to avoid penalties and reimbursement demands from Medicare. Many companies and law firms specialize in Medicare Secondary Payer compliance and can provide expert guidance.

MMSEA Section 111 Reporting Fills a Gap for CMS

Although the Medicare Secondary Payer (MSP) provisions were long-established, CMS had no easy way to know when there was another, primary payer available. CMS relied on individual Medicare beneficiaries to alert them to other payers. There was no incentive for an individual beneficiary to do this because, so long as their medical bills were paid, the Medicare beneficiary likely didn’t care how it was paid for. Moreover, in the case of claim settlements, beneficiaries would rather pocket their settlement money than set some aside for Medicare!

This created challenges for CMS in enforcing the MSP statutes. In response, Congress strengthened CMS’s hand with the introduction of MMSEA Section 111 reporting (also known as Mandatory Insurer Reporting). It was created to fill the gap in Medicare’s view, mandating insurers and self-insurers to report information to CMS about the health care coverage of, or settlements, judgments, awards, or other payments to, Medicare beneficiaries. While this reporting serves an essential purpose in facilitating Medicare coordination and compliance, it creates yet another set of compliance challenges because it shifts the burden of notifying CMS of primary payer responsibilities from the individual Medicare beneficiaries to the insurers and self-insureds.

Overall, the implementation of MMSEA Section 111 reporting strengthened the enforcement of the MSP provisions by preventing and improving the identification and recovery of improper Medicare payments. It enhanced CMS’s ability to identify situations where other entities have primary payment responsibility, ensuring that Medicare remains the secondary payer and reducing improper billing to the program.

But complying with MMSEA Section 111 reporting involves following complex technical requirements. Reporting entities must navigate the intricacies of data collection, formatting, and submission through CMS-approved reporting channels. The process demands a thorough understanding of the reporting guidelines and protocols to ensure accurate and timely submissions.

Self-insured entities and insurance carriers may encounter challenges in gathering the necessary data for reporting. This includes identifying and tracking reportable events, collecting beneficiary information, including Social Security number and medical diagnosis information, and reconciling data across multiple systems or entities.

Failure to comply with MMSEA Section 111 reporting requirements can have significant consequences. Non-compliance, including inaccurate reporting, may result in penalties, fines or even litigation.

How an MMSEA Section 111 Reporting Solution Facilitates MSP Compliance

To mitigate these compliance challenges, organizations can consider utilizing MMSEA Section 111 reporting software to simplify and streamline the reporting workflow.

Such software offers a range of features and capabilities designed specifically for compliance with CMS requirements. These solutions provide user-friendly interfaces that guide users through the data collection, formatting, and submission processes. With built in validations and checks, they help ensure the accuracy and completeness of the reports, minimizing the risk of rejections and penalties.

By streamlining the workflow, an MMSEA Section 111 reporting solution can save time and effort. These solutions automate data gathering from internal claims systems, consolidate the necessary information, and generate the required reports to CMS. This eliminates the need for manual data entry, removes the burden of maintaining audit trails, and reduces the likelihood of errors.

Although some companies create their own systems for electronic reporting to CMS, the reporting rules change regularly and keeping home grown systems up to date requires ongoing effort and resources. Therefore, ensuring compliance with CMS reporting requirements is a key aspect of MMSEA Section 111 reporting solutions. These solutions stay up to date with the latest CMS guidelines and regulations, incorporating any changes. This ensures organizations stay compliant and avoid civil money penalties (CMPs).

Lastly, the vendors who provide MMSEA Section 111 reporting solutions can provide expert support and guidance throughout the reporting journey. They offer dedicated customer support teams that are well-versed in CMS reporting requirements. These experts can assist organizations in navigating any challenges, answering questions and providing personalized guidance to ensure successful reporting to CMS.

Unlock the Power of Seamless Reporting With MIR Express by APP Tech

In this comprehensive guide, we’ve explored CMS and its vital role in the health care industry. CMS’s impact is far-reaching, from administering Medicare and Medicaid programs to ensuring quality care and combating fraud. Understanding the complexities of CMS programs is essential for self-insured entities to navigate the ever-evolving landscape successfully.

When it comes to MMSEA Section 111 reporting, APP Tech’s MIR Express emerges as the ideal solution. As a user-friendly, secure, and web-based system, MIR Express simplifies the mandatory insurer reporting process for non-group health plans (NGHP). EDI and API integration options eliminate redundant data entry and can fully automate sending your data to APP Tech. With continuous updates and 100 percent adherence to CMS requirements, MIR Express streamlines data collection, minimizes errors, and maximizes compliance.

By incorporating MIR Express into your reporting workflow, your company can minimize exposure to civil money penalties (CMPs) and streamline claims reporting. Enjoy peace of mind knowing that your reports are pre-validated, ensuring accuracy and compliance. With efficient reporting, your administrative teams gain valuable time to focus on other critical processes.

Request a demo today and unlock the power of seamless, compliant reporting with MIR Express.