Evaluating claims isn’t easy. Even with seemingly straightforward claims, you must sift through a myriad of sometimes conflicting information from different sources, to piece together an accurate picture.
Evaluating complex behavioral health claims and behavioral aspects of physical claims can be even more challenging. Within information from physicians, psychologists, the employee, and the employer, there is plenty of room for inconsistencies and confusion in the search for a precise path forward.
For claims professionals (managers, adjusters, and nurses), having their own foundation of support is invaluable. The R3c roundtable is a regular meeting with a dedicated clinician who provides an objective viewpoint, education, and collaboration to enhance a claims team’s decision accuracy, timeliness, and outcomes.
A necessary resource for claims management
Davis paused as he passed the doorway of Maxine’s office. “Hey, I’m going to have to miss the roundtable call today. Got backed up claims,” he said with an apologetic smile.
Maxine looked up from her computer monitor. As claims manager for a regional financial institution, she was no stranger to excuses. And, after 30 years in the industry, she knew how to get to the heart of the problem.
Maxine smiled sweetly over her glasses. “Davis? Sit down.”
Davis wasn’t new to benefits, but was new to her department, having transferred in as assistant claims manager from the western region last month. She knew he was eyeing her upcoming retirement date almost as closely as she was, and she was grooming him to be her replacement. That made today’s cancellation worrisome.
Davis muffled a sigh and sat in the chair across from Maxine’s desk.
“Since you transferred here, we’ve had several roundtables, and I believe you’ve missed all of them,” Maxine said.
“Maxine, you know how backed up we all are with claims. Who has time for yet another meeting every week with some outsider who’ll just question our decisions?” Davis said. “Frankly, I’m surprised you go for this. We didn’t do this in the western region. It’s a real time suck.”
Maxine took one breath, then another. She imagined she could hear her husband’s voice in her ear, reminding her to stay calm and watch her blood pressure. She reminded herself that even though Davis could be impatient, he was dedicated to the company and to his team.
“Davis, as a claims manager, you have a discerning eye and an ability to integrate various sources of information to form an accurate big picture,” Maxine began. “But have you ever come across a claim that was difficult to resolve, or that you may have resolved but didn’t feel good about? Maybe you wondered if you’d made the right decisions? Gotten all of the information? Asked all of the right questions?”
Davis shifted slightly in his chair. “Well, maybe, but that’s part of the job. We have to make our best determination, based on the information we have. For the really complicated claims I just send them out for an IME, especially if they have a behavioral health diagnosis.”
Maxine nodded in agreement. “Exactly. And what if, on those most difficult cases, you could turn to experts who could help you ensure that your case conceptualization and determination were accurate? Just think about how much money and time could be saved if you had more training around behavioral health diagnoses and only had to refer out the claims that required outside expertise.”
Davis nodded, “That is one of the biggest stressors we have—not only being efficient in making determinations, but knowing we’ve taken the right steps to reach the right conclusion.”
Improve claim accuracy, claimant interactions, and provider discussions
With R3 Continuum’s roundtable consultation, your team will receive real-time behavioral health case management training from a licensed, doctorate level psychologist. Roundtables are conveniently held via telephone, video conference, or in person. Benefits include:
- Enhancing the ability to conceptualize claims to make more informed, accurate decisions
- Providing skills for maintaining objectivity, even when managing emotionally charged claims
- Improving interactions with claimants and providers
- Reducing unnecessary or untimely independent medical examination (IME) or peer review referrals
Better results through collaboration
“A few months ago, an employee was struggling to return to work,” Maxine told Davis.
“Although his symptoms first appeared to be physical, eventually, it became clear that there was a behavioral health aspect as well, but we couldn’t really identify what it was. The claims manager was getting inconsistent information on the diagnosis, the treatment, and the plan to return to work. Was it poor care? Lack of treatment? Poor documentation? We discussed it within the department, but we really didn’t have the medical expertise to make some of these assessments,” Maxine explained.
“Let me guess. You collaborated with the consultant from the roundtable,” Davis said.
Maxine nodded. “Exactly. The consultant was the sounding board we needed, providing clinical expertise and recommendations that were in compliance with our policies and regulatory requirements. And, as we talked through the case, the claims manager better understood how to make sure she had the information necessary to make an accurate decision. In the end, not only did the claims manager treat the employee fairly, but by taking the right steps, she represented the company well, reducing the likelihood of an IME or peer review.”
Davis thought about it for a moment, then nodded. “I imagine that, as an added bonus, knowing her course of action was valid made her feel great about getting through a sticky case, and reduced her own stress.”
“So,” Maxine said. “See you on the video call this afternoon?” Davis stood up. “I’ll be there. I may have a situation I want to discuss at the roundtable.”
Maxine smiled, pleased.
Expert training and support that enhances your benefits team
When you need supporting expertise in work absence, disability, or workers’ compensation, particularly when behavioral health is involved, put to work the experience of R3c. Our licensed, doctorate level clinicians, supervised by our medical director, can work with your claims team to ensure a course of action that results in an accurate and efficient claim determination.
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