Leveraging Tech and AI (With a Compassion) in Workers’ Comp Management

Episode Notes

Transcript

Announcer:

Workers’ Comp Matters, the podcast dedicated to the laws, the landmark cases, and the people that make up the diverse world of workers’ compensation. Here are your hosts, Jud and Alan Pierce.

Judson Pierce:

Hello and welcome to another edition of Workers’ Comp Matters. My name is Judson Pierce, coming to you from Lovely Salem, Massachusetts. I’m an attorney at the law firm, Pierce Napolitano. Today we are going to be discussing with our special guest the use of analytics for outcomes in workers’ compensation cases. Today, we are joined by Ryan Murphy, Vice President of Product Enterprise Claims at CorVel. Hey,

Ryan Murphy:

Justin. Thanks for having me.

Judson Pierce:

Yeah, thanks for being here, Ryan. Tell us a little bit about yourself and your organization.

Ryan Murphy:

Sure. So as the vice president of the product on enterprise claims, my primary responsibilities are going to be creating tools that create efficiencies within the claim management process. So making things a little bit easier for the claim team to actually manage the claims and focus less on task-oriented activities and behaviors, but really focusing on the outcome of the claims. And for our clients, what that provides is shorter claim durations, better reserving practices, and better outcomes overall.

Judson Pierce:

Throughout your career, Ryan, you’ve managed large national workers’ comp programs and you’ve focused on program implementation and analytics and operational performance. Tell us how your background is lending itself to your work today.

Ryan Murphy:

Sure. So I have a finance background, so the numbers of the claim process and reserving all make sense to me. But also through my schooling, also you learn how to create efficiencies and where are some of the workflow snags or backlogs created and how can we better operationalize some of the tasks within the organization. So claim management has plenty of opportunities to remove some log jams or constraints within the system and leveraging artificial intelligence as well as some analytics tools to remove those constraints within the system will ultimately create a better outcome for our clients as well as a better system for a claim specialist. So my background in finance, as well as with some of the operational knowledge that I’ve been able to attain throughout my career has been helpful.

Judson Pierce:

Yeah. CorVel, for those who are listening who don’t really know, CorVel is an organization that’s been around for nearly 40 years, and it acts as a third party administrator in the workers’ comp realm. I know CorVel also handles other insurances like auto and property, but in the workers’ comp context, it’s a third party administrator. Can you explain a little bit about what that means?

Ryan Murphy:

Sure. So essentially, we are administrating the benefits that an insurance company and a client agree to. So a client will go out and buy insurance for, in this example, workers’ compensation. The carrier will say that certain coverages are afforded underneath this policy. And as a third party administrator, we administer those benefits according to the policy and any jurisdictional requirements that may be within those policies as well. So with workers’ compensation, we determine compensability whether or not a claim is going to be accepted or denied. We will pay medical benefits and time wage loss benefits for the injured workers. And really our focus is to make sure that we’re following jurisdictional rules, following the policy language, but then also making sure that we achieve a safe return to work for the injured worker. Really, that’s the focus. It’s not how quickly we can achieve that. It is, but really what we want to focus on is a safe return to work and one that can be we don’t have any recidivism where folks are going to work and then they’re bouncing back out of work.

We want it to be a safe return and a long-term return to work.

Judson Pierce:

How is that done? I mean, do you engage the assistance of legal counsel at the onset of a claim? Say an injured worker has a work injury, it’s in a jurisdiction that you’re overseeing. And do you ask for an attorney’s help in that local area to see if that attorney would say, no, this is not compensable, or no, it is compensable? Or do you guys make up that decision on your own?

Ryan Murphy:

Typically, we can make those decisions on our own. We will find some cases that are complicated. The facts of the case are unusual perhaps, and they fall outside of what we are used to seeing. And in those cases, we will rely on defense counsel for some guidance, some case law, and help us make those decisions.

Judson Pierce:

You have a background also as a claims adjuster, right?

Ryan Murphy:

Yes.

Judson Pierce:

How is your work now compared to that, or how does it inform your job now? I

Ryan Murphy:

Was a little different. It was a little different when I was handling claims. We had paper mail. We didn’t have email. We had faxes instead of text messaging. Everything was a little bit different back then, but the process is still the same. We’re getting the claims in, we’re making decisions, we’re documenting our work, and then we are closing the file, whatever method that may take. So it helps … I guess I have an understanding of what the claims specialists go through. It’s a very difficult role. You’ve got a lot of communication streams coming at you from a lot of different directions and you have to be able to multitask and really have a very good organizational, I guess, mindset to keep things straight. So I know it’s busy, I know it’s challenging, and anytime I can help create some efficiencies along the way, take some of the task-oriented things off of you like, did I take the recorded statement, yes or no, and checking that box.

Just kind of moving things along so that you’re focused more on the outcome and a good investigation. You can actually get the medical records. Some notes are automated for you. Just taking some of that task work off of you so you can focus more on driving a claim forward towards closing resolution.

Judson Pierce:

What are you seeing right now as the biggest opportunities to improve operational efficiency and financial outcomes? And for my standpoint as an injured worker advocate, recovery for injured workers.

Ryan Murphy:

So one of the things that we’re seeing here is being able to automate administrative work. So we’ve talked about that a little bit and just moving away from the task-oriented activities. So moving away from the task-oriented activities provides more time to the claim specialist to focus on what do I really need to do? I need to do a thorough investigation. I need to make sure that it’s touching on all aspects of potential issues and concerns that I have or the clients may have. So if I can do that in 48 hours versus 24 hours, but I get a really thorough investigation completed, that’s of value. Making sure that we can close some communication gaps. So one of the things that really tends to drive litigation is when an injured worker doesn’t know what’s going to happen next, and making sure that they understand the complete process along the way.

It’s easy for us as a claim specialist to look at the claim and think that, “Hey, this is Judd’s claim here. I know exactly what’s going on. He knows exactly what’s going on, but what we tend to lose sight of is it’s Judge’s first claim perhaps and it’s confusing. You are off work, you don’t know where your next check is coming from, maybe you’re afraid that maybe you’re going to lose your job. Well, we need to make sure that we communicate to you every step of the process so that you’re not confused along the way. It’s fine that we might send you for an independent medical exam if there are questions. It’s not casting doubt on anything. It’s just confirming some of the details of the incident maybe. So making sure we have that communication dialed in, and then also just making sure that we use technology to give time back to our supervisors as well.

We talk a lot about the claim specialists and saving time on their desk. But as a supervisor, if we can auto-assign claims and take that task off of their desk, they have more time to actually get in the claim, serve as a mentor, and make sure claims are staying the track.

Judson Pierce:

Yeah. We had as a prior guest not too long ago, a professor over at Drake University, Dr. Musselman, and she talked about the importance of empathy in claims and the role that claims adjusters play in providing that person who can support the injured worker, especially when they’re representing themselves pro se. How would you define empathy in the role and process of CorVel and its management?

Ryan Murphy:

Sure. Well, it starts at the beginning, and that’s at intake. So a claim is going to be reported, and there’s a nurse that you can speak with, and the nurse will take some of the details of the incident and maybe even be able to prevent that claim from even turning into a claim. So we can have the nurse speak to you about first aid. Maybe it’s something very simple that they can resolve over the phone and you’re done. Now it’s a report only claim as opposed to an actual medical only or indemnity claim. But if not, if it’s something a little bit more complicated, you can talk to a care advocate nurse who’s going to walk you through the medical process and they’re going to be on the claim for the first 30 days to help you navigate the medical channels that you’re going to have to be going through.

And that right there is a little bit of a different approach that we have here at CorVel where we are putting the nurse at the very front of the case as opposed to something that might be seen as a little bit more confrontational, perhaps a claim specialist calling me. “You’re trying to deny my claim.” People have that mindset sometimes, but having the nurse at the front end and then the claim specialist behind that to say, “I hope you’ve spoken to the nurse,” whoever that may be, they’ve outlined their process along the claim process. My role is to make sure you return to work safely, help coordinate your medical treatment and address any questions you have along the way and explain that I talk to you, the injured worker, I talk to your employer, and I make sure everyone is on the same page. So the claim specialist is the quarterback and they have to understand that the person on the other end of the line, the injured worker oftentimes is going through this for the first time.

And with empathy, understand that the other person may be confused or scared or worried about their livelihood, and we need to make sure that we understand that and address any questions they have upfront.

Judson Pierce:

Why don’t we take this moment to have our first break and we will be right back with Vice President of Product Development, Ryan Murphy. And we’re back. With Ryan Murphy, there’s an adversarial nature just embedded in the system, but there really ought not to be when it comes to what workers’ comp is designed to do. Workers’ comp is designed to present a speedy but reasonable level of benefit for when an injured worker is out of work or requires medical treatment for something that happened at work. And in return for that, the injured worker has given up his or her right to sue for negligence or any other type of claim under the tort system they might have. So help us figure out what it really means in terms of putting aside the adversarial and joining together as sort of a supportive team to all make this go a little bit easier for everyone involved.

I guess my question really is, how can it be less adversarial?

Ryan Murphy:

Yeah, so it can be less adversarial by making sure that number one, you have that channel of communication open with the injured worker. So one way that we do that is through texting. Initial phone calls are always sometimes the most difficult thing to do as a claim specialist because you can’t get hold of somebody, they don’t recognize their phone number. Now with texting, you can actually schedule a time to communicate with Dean Gorger about their injury. So right there, you’re kind of meeting them where they are and you’re saying, “Okay, if this time works for you, I’ll make it work for me. I’ll put it on my calendar. I’ll reach out to you. Here’s the number you can expect to receive a phone call from.” So right there, you’re kind of meeting them where they are, meeting them at their level to understand, “I’m here for you.

I’m going to make myself available for you, and we’re going to talk through whatever issues and concerns you may have. ” Making it less about the facts of the injury, those are important and we need to collect those and we need to make a compensability decision down the road, but you can get all that information a lot of times through just a normal course of a discussion with the injured worker and make it less of an interview and more of a discussion.

Judson Pierce:

I don’t think it’s necessarily adversarial for an injured worker to get him or herself a lawyer. In fact, we encourage it. We think it’s a very important thing to do. You’re speaking in the terms of speaking directly to the injured worker. What if they are represented? How do you go about it then?

Ryan Murphy:

Yeah, so it’s a little bit more difficult then because we can’t have direct communication with the injured worker, but what we can do is make sure that the medical process flows well for them. So there we’re more in the background and making sure that we can coordinate medical care, make sure their medical bills are taken care of and we pay them. And then make sure that we also have direct communication with their representative. Make sure that they understand that we’re working on the claim, payments are being made on time. If they are off work, we’re releasing those checks timely. There’s no delay in those because ultimately that’s what’s going to cause the most noise is if I’m off work and I’m not receiving pay for my time off work and I have a compensable injury, that’s going to create a lot of noise for the injured workers representative, claim specialist, everybody.

So make sure that wage benefits are paid timely. And then one of the lagging indicators is medical bills. A lot of times you don’t know you have a medical bill that hasn’t been paid until months later, but making sure that everything does get paid timely. And if there is a dispute on something, communicate that immediately to the plaintiff’s attorney, and they will then communicate it to the injured worker and say, “This was denied. Here’s why you may be seeing a bill for this. ” But that all gets wrapped up in the end a lot of times too. But it really comes down to communicating effectively and timely.

Judson Pierce:

Where are ways in which claims adjusters can be assisted in terms of guidance or free up their time in some respects to give more attention to the injured worker? I’m talking about artificial intelligence. Where are these claims going with artificial intelligence today? How is CorVel leading in that movement?

Ryan Murphy:

Sure. So artificial intelligence, I refer to it as a decision support tool. And really what that is, is it just presents information to the end user, whether it be the claim specialist or the supervisor or claim manager, whomever is looking at the file, it will aggregate data and present it to you to make a decision. So oftentimes we see predictive modeling being helpful when we talk about claim risk scores. Here’s a claim that has a high risk score for whatever reason. Maybe it’s age or comorbidities or type of work that’s being done, a heavy job, for example. And this is a score or this is a claim rather that needs to have immediate attention. So you’re getting the right resources on that claim immediately. So that’s predictive analytics, predicting which claims could potentially be large claims at the onset so we can get the right resources to those claims immediately.

And then we’re also using artificial intelligence to help to support decisions along the way by claim summarization. So imagine you take over a large claim that’s been a couple years old, managed by another TPA that now comes to you and now you’re managing it and you have two years of history. You could spend hours reading that file and all the documents attached to it to get caught up and you’ve got 120 of them to review. Well, now we’ve got claim summarization and you can summarize the claim to give you a real time update on what’s going on with the claim, a complete history that might be a page or too long, but it’s a lot easier than reading hundreds of pages of notes and documents to get caught up on a file. So right there is creating an efficiency for the claim team. So to go through 120 claims might take you two or three days now as opposed to a month or more to get caught up.

It can also call out next steps. So it’ll tell you this person needs to get paid on Tuesday. For example, they’re off work. When you have a takeover file, a lot of times that can get lost in the shuffle. So injured workers benefit from this process as well. So that’s just one of the ways we’re doing it. But also we have automated claim notes. So if you complete a task within the system, a diary to do something in the future, you complete that, a note gets automatically entered into the claim so that it’s one less thing you have to do to go in and document what you did. I’ve already documented in the test screen here that I’ve done this. Now it’s also in the claim notes that I’ve done this. So just automating notes for folks that always have to be vetted by the end user.

So it’s a decision support tool, it’s not a decision tool. So ultimately what it does is it presents information to the claim specialist or the supervisor. If I’m the claim specialist, I have to look at it, make sure it’s accurate, and then actually validate it, and then it gets entered into the file. So AI is very helpful, but it’s never going to take the place of the actual person making those decisions because ultimately that’s what the claim specialist is there for, is to make those important decisions at intervals alone in the claim.

Judson Pierce:

Absolutely. What I’ve been learning through trying to study it and get to the bottom of AI is that it really is person first, then use the tool, then person out. So you’ve got to sort of buttress the support tool, keeping it in the middle and always have those checks and balances, right?

Ryan Murphy:

Absolutely. All

Judson Pierce:

Right. Why don’t we take this opportunity to have our second break of the podcast? We’ll be right back with Ryan Murphy of Corbel. All right, and we’re back. Ryan, tell me a little bit about the difficulties that you see in terms of taking over a claim, like you said, or things falling through the cracks when there are just so many claims. Now, having said that, there are a lesser amount of claims that there have been in the past for

Ryan Murphy:

Whatever

Judson Pierce:

Reason. I think workplaces are getting more safe, people are understanding how to keep themselves safe. We’re moving from an industrial economy to a more sophisticated, nuanced economy. There are many reasons why there are less claims, but yet claims are still being mishandled in some ways. Tell us a little bit about how CorVel can help against that. I spend a large part of my day as an attorney practitioner calling insurance adjusters saying, “My client’s been off repetitive pay now for three weeks. Why has he not had a check for three weeks?” Or, “This medical bill keeps coming to him. We’ve sent it to you. ” Help us inform the public about what CorVel is doing to manage those daily necessities that we’re seeing take over.

Ryan Murphy:

It’s always a challenge when you have takeover files, like you mentioned and getting your arms around those. So the claim summarization is the tool really that’s going to help us manage that process more efficiently and effectively. And getting that summary of the claim upfront within a minute and a half, two minutes of when you request it, you’ve got a full summary of a claim that’s maybe two or three years old and is complex that outlines potential next steps or forms that need to be filed that weren’t filed previously is huge. Authorizations for surgery, for example, will be included in that summary so that if we do get medical bills, like you mentioned, we’ll know that this surgery has previously been approved. We’re going to pay those bills, we’re going to take care of it going forward, but it will also call out that this person is off of work.

They’ve been receiving a check for $100 a week, and the next check is due on X date, and we can then make sure that we program either for repetitive pay, like you mentioned, or just put a note in the file to go in there and do it next week, whatever the next due date is. So AI has transformed the intake of takeover files for CorVel and largely for the TPA industry. It is significantly reducing the time spent reading a file, combing through the details when they’re all presented to you in a nice summarized fashion.

Judson Pierce:

Well, I think that you’ve really helped us understand a little bit more about what’s going on behind the scenes, so to speak. As lawyers, as injured workers, we don’t see what’s happening in the other realm, which is where the payments are coming from, where the medical bills are being paid and how they’re being scrutinized. Is there anything else you’d like to leave with us today or leave with the audience about your mission and the organization’s mission?

Ryan Murphy:

Sure. So thanks for the time. I really appreciate it, Jeff.This has been fun. The biggest takeaway is that AI is transforming the way we do work, everybody. Every industry is being transformed by this and CorVel and TPA market are not immune to it, and it’s really decreasing timeframes for getting work done. But at the end of the day, like I mentioned earlier, there has to be a human at the other end of this that is making the decisions and actually managing the outcome of whatever it is we’re trying to do. So AI is not going anywhere. It’s going to be more and more embedded in what we do, and it’s exciting to see where it’s going to take us. The future’s bright. It’s exciting.

Judson Pierce:

Well, definitely appreciate your time here today, Ryan. And from all of us here at workers’ comp Matters, make it a day that matters. We’ll talk to you soon. Take care.

Continue Reading