Group Disability Management Claims Stop, Review, Take your Blood Pressure

1
Group Disability Management ClaimsStop, Review,
Take your Blood Pressure

• July 26, 2005
• GDMS Process Improvement Project
• Weekly Leaders Obstacles vs
• Solutions Pow Wow
• Remember the Mission

2
Begin with the End in Mind s covey

• Basic Habit of Effectiveness
• Mental creation precedes physical creation
• 1st create the mental thought for desired results
• 2nd the physical production of desired
  resultswere writing the program now

• Create and apply personal and organizational
  mission statements as constitutions for daily
  living
• Envision the desired results and important
  values to guide activities or endeavors

3
Synergizeala Stephen Covey

• Results-oriented, positive synergy
• Examining, exploring, seeking diverse
  perspectives openly enough to alter or complete
  your paradigm
• Cooperate
• Having a mutually agreed-upon end in mind
• Worth the effort and highly effective
• A process

4
Paradigmala Stephen Covey

• The way an individual perceives, understands, and
  interprets the surrounding worldour strongly
  reinforced mental map
• Paradigm Shift If we want significant change we
  must change our paradigms

5
Changing our Paradigms

• We can service anything that is sold without
  adding to staff
• We can cover vacations without special planning
  (up to 8 out at a time)
• We can prepare for growth without incurring
  expense
• Incurring expense exposes us to risk
• We can prepare for growth without taking any risk
• We can manage by responding to claim analyst
  percolating noise
• We can manage without a strategic plan
• We can balance our work by playing the 5 day
  Float

6
Effectivenessala Stephen Covey

• Production the desired results produced (golden
  eggs)
• Production Capability maintaining, preserving
  and enhancing the resources that produce the
  desired results (the goose)
• Effectiveness is the balance of the two

7
Our Mission

• To create a production, claim analysis and
  service capability
• That will meet the sales growth plan for the next
  3 years

8
Henry David Thoreau

• For every thousand hacking at the leaves of evil,
  there is one striking at the root

9
Todays Obstacles to striking at the Root

• Earned Vacation Time
• Early work schedules
• Untrained new hires
• Unhired new customer service reps
• Time for new role orientation for analysts and
  team leaders
• Snowball-impact of backlog double, triple,
  quadruple the calls
• Increased volume of new claims

• Completion of Training modules
• PCA Training (mentoring on the floor)
• Removing the case load from the Team Leader so
  they can mentor and coach and do re-audits
• Morale/Attitude
• Unloaded PCA Comments

10
Put First Things First- s. covey

• Focus on the truly important and say no to the
  unimportant
• Plan weekly and implement daily
• Things which matter most must never be at the
  mercy of things which matter least. Goethe

11
HOLD ON!ala s. brenner

• What are we trying to do here?
• Solutions should be in sync with the Mission and
  our Goals

12
Best Practices Time Service

• 2 day turnaround on STD
• 5 day turnaround on LTD
• STD new claim decision in 5-7 working days, 10
  calendar days
• LTD new claim decision in 21 calendar days
• Return calls and e-mails SAME DAY
• STD AND LTD 24 hours in clerical, on analysts
  desk in lt48 hours
• ALL any occ determinations communicated prior to
  any occ change of definition dates (and other
  limited benefit conditions)
• Appeals referred within 48 hours of receipt

13
Best Practice Phone, Fax, Mail

• Apply the hierarchy
• Use the phone to complete gaps
• 2 calls over 2 days to recover information on new
  claim submissions
• Loop the claimant (certholder) when provider is
  not responding
• Notify the employer (policyholder) when claim
  investigation may create a delay
• Make a status call out at the midpoint

14
Best Practice Clinical Pathway

• Management vs Co-Management
• Reduce Risk
• Facilitate RTW
• Expense Management

15
Best Practice Initiate Pay Analyst

• Initial STD thru Optimum
• Clinical Review of M/N and Self Reported Symptoms
  and Complex Prognosis
• FIFO
• Medical Certification vs Medical Records
• Telephonic Development
• 80 Decision within 7 work days/10 calendar days
  from claim notification

16
Best Practice RTW Claims Analyst

• Ongoing STD
• LTD Decision
• First 6 months of LTD

17
Best Practice Resolution Claims Analyst

• SSDI offset
• Any Occ and other LBC determinations
• Closures own occ
• Claim Review presentations

18
Best Practice Low Impact LTD

• Benefit Specialist Redundant
• Death Claim handling
• Refer Back Opportunities
• POD dignity

19
Best Practices Roles and Responsibilities

• Every staff position has specific roles and
  responsibilities, measurables, outcome
  expectations, time service and performance goals
• RR document prepared for each position and
  communicated to associate
• Weekly, Monthly, Midyear, Annual, and associate
  work tools linked to RR
• Output and Outcome measures are available to
  everyone to self-monitor

20
Remember? Lets Get Started May 15, 2005

• Agree on Best Practices
• Pilot new roles
• Begin Co-Management Pathways
• Communicate Service Standards
• Utilize borrowed nurse
• Revise caseloads
• Assign specialty tasks

• Revise Re-Audits and Written processes to match
  expectations
• Calibrate Auditors
• Monitor workflow, revise as needed
• Monitor backlog
• Monitor days to decision
• Monitor Nurse caseload

21
Win Win for the staff

• Desk coverage while they take earned time off
• Timely claim handlingno backlog, reduced phone
  calls, increased customer satisfaction
• Individual developmenttime for training, for
  learning through doing
• Staffing modelearned staff per projected sales

22
More win win

• Formal training for new hires to reduce the new
  hire/productivity lag
• Metrics and measures for evenly calibrated and
  fair individual performance assessment
• Ongoing feedback and coaching for personal
  development
• Opportunity to try new roles

23
March of the Penguins

• The Penguins make our job look easy
• Solutions