Stop, review, take your blood pressure


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Stop, review, take your blood pressure

  1. 1. Group Disability Management Claims Stop, Review, Take your Blood Pressure July 26, 2005 GDMS Process Improvement Project Weekly Leaders’ Obstacles vs Solutions Pow Wow Remember the Mission
  2. 2. Begin with the End in Mind s covey <ul><li>Basic Habit of Effectiveness </li></ul><ul><li>Mental creation precedes physical creation </li></ul><ul><li>1 st create the mental thought for desired results </li></ul><ul><li>2 nd the physical production of desired results—we’re writing the program now </li></ul><ul><li>Create and apply personal and organizational mission statements as constitutions for daily living </li></ul><ul><li>Envision the desired results and important values to guide activities or endeavors </li></ul>
  3. 3. Synergize ala Stephen Covey <ul><li>Results-oriented, positive synergy </li></ul><ul><li>Examining, exploring, seeking diverse perspectives openly enough to alter or complete your paradigm* </li></ul><ul><li>Cooperate </li></ul><ul><li>Having a mutually agreed-upon end in mind </li></ul><ul><li>Worth the effort and highly effective </li></ul><ul><li>A process </li></ul>
  4. 4. Paradigm ala Stephen Covey <ul><li>The way an individual perceives, understands, and interprets the surrounding world—our strongly reinforced mental map </li></ul><ul><li>Paradigm Shift: “If we want significant change we must change our paradigms” </li></ul>
  5. 5. Changing our Paradigms <ul><li>We can service anything that is sold without adding to staff </li></ul><ul><li>We can cover vacations without special planning (up to 8 out at a time) </li></ul><ul><li>We can prepare for growth without incurring expense </li></ul><ul><li>Incurring expense exposes us to risk </li></ul><ul><li>We can prepare for growth without taking any risk </li></ul><ul><li>We can manage by responding to claim analyst “percolating noise” </li></ul><ul><li>We can manage without a strategic plan </li></ul><ul><li>We can balance our work by playing the 5 day Float </li></ul>
  6. 6. Effectiveness ala Stephen Covey <ul><li>Production: the desired results produced (golden eggs) </li></ul><ul><li>Production Capability: maintaining, preserving and enhancing the resources that produce the desired results (the goose) </li></ul><ul><li>Effectiveness is the balance of the two </li></ul>
  7. 7. Our Mission <ul><li>To create a production, claim analysis and service capability </li></ul><ul><li>That will meet the sales growth plan for the next 3 years </li></ul>
  8. 8. Henry David Thoreau <ul><li>For every thousand hacking at the leaves of evil, there is one striking at the root </li></ul>
  9. 9. Today’s Obstacles to striking at the Root <ul><li>Earned Vacation Time </li></ul><ul><li>Early work schedules </li></ul><ul><li>Untrained new hires </li></ul><ul><li>Unhired new customer service reps </li></ul><ul><li>Time for new role orientation for analysts and team leaders </li></ul><ul><li>Snowball-impact of backlog; double, triple, quadruple the calls </li></ul><ul><li>Increased volume of new claims </li></ul><ul><li>Completion of Training modules </li></ul><ul><li>PCA Training (mentoring on the floor) </li></ul><ul><li>Removing the case load from the Team Leader so they can mentor and coach and do re-audits </li></ul><ul><li>Morale/Attitude </li></ul><ul><li>Unloaded PCA Comments </li></ul>
  10. 10. Put First Things First- s. covey <ul><li>Focus on the truly important and say no to the unimportant </li></ul><ul><li>Plan weekly and implement daily </li></ul><ul><li>“Things which matter most must never be at the mercy of things which matter least.” Goethe </li></ul>
  11. 11. HOLD ON! ala s. brenner <ul><li>What are we trying to do here? </li></ul><ul><li>Solutions should be in sync with the Mission and our Goals: </li></ul>
  12. 12. Best Practices: Time Service <ul><li>2 day turnaround on STD </li></ul><ul><li>5 day turnaround on LTD </li></ul><ul><li>STD new claim decision in 5-7 working days, 10 calendar days </li></ul><ul><li>LTD new claim decision in 21 calendar days </li></ul><ul><li>Return calls and e-mails SAME DAY </li></ul><ul><li>STD AND LTD 24 hours in clerical, on analyst’s desk in <48 hours </li></ul><ul><li>ALL any occ determinations communicated prior to any occ change of definition dates (and other limited benefit conditions) </li></ul><ul><li>Appeals referred within 48 hours of receipt </li></ul>
  13. 13. Best Practice: Phone, Fax, Mail <ul><li>Apply the hierarchy </li></ul><ul><li>Use the phone to complete gaps </li></ul><ul><li>2 calls over 2 days to recover information on new claim submissions </li></ul><ul><li>Loop the claimant (certholder) when provider is not responding </li></ul><ul><li>Notify the employer (policyholder) when claim investigation may create a delay </li></ul><ul><li>Make a status call out at the midpoint </li></ul>
  14. 14. Best Practice: Clinical Pathway <ul><li>Management vs Co-Management </li></ul><ul><li>Reduce Risk </li></ul><ul><li>Facilitate RTW </li></ul><ul><li>Expense Management </li></ul>
  15. 15. Best Practice: Initiate Pay Analyst <ul><li>Initial STD thru Optimum </li></ul><ul><li>Clinical Review of M/N and Self Reported Symptoms and Complex Prognosis </li></ul><ul><li>FIFO </li></ul><ul><li>Medical Certification vs Medical Records </li></ul><ul><li>Telephonic Development </li></ul><ul><li>80% Decision within 7 work days/10 calendar days from claim notification </li></ul>
  16. 16. Best Practice: RTW Claims Analyst <ul><li>Ongoing STD </li></ul><ul><li>LTD Decision </li></ul><ul><li>First 6 months of LTD </li></ul>
  17. 17. Best Practice: Resolution Claims Analyst <ul><li>SSDI offset </li></ul><ul><li>Any Occ and other LBC determinations </li></ul><ul><li>Closures own occ </li></ul><ul><li>Claim Review presentations </li></ul>
  18. 18. Best Practice: Low Impact LTD <ul><li>Benefit Specialist – Redundant </li></ul><ul><li>Death Claim handling </li></ul><ul><li>Refer Back Opportunities </li></ul><ul><li>POD dignity </li></ul>
  19. 19. Best Practices: Roles and Responsibilities <ul><li>Every staff position has specific roles and responsibilities, measurables, outcome expectations, time service and performance goals </li></ul><ul><li>R&R document prepared for each position and communicated to associate </li></ul><ul><li>Weekly, Monthly, Midyear, Annual, and associate work tools linked to R&R </li></ul><ul><li>Output and Outcome measures are available to everyone to self-monitor </li></ul>
  20. 20. Remember? “Let’s Get Started May 15, 2005” <ul><li>Agree on Best Practices </li></ul><ul><li>Pilot new roles </li></ul><ul><li>Begin Co-Management Pathways </li></ul><ul><li>Communicate Service Standards </li></ul><ul><li>Utilize “borrowed nurse” </li></ul><ul><li>Revise caseloads </li></ul><ul><li>Assign specialty tasks </li></ul><ul><li>Revise Re-Audits and Written processes to match expectations </li></ul><ul><li>Calibrate Auditors </li></ul><ul><li>Monitor workflow, revise as needed </li></ul><ul><li>Monitor backlog </li></ul><ul><li>Monitor days to decision </li></ul><ul><li>Monitor Nurse caseload </li></ul>
  21. 21. Win Win for the staff <ul><li>Desk coverage while they take earned time off </li></ul><ul><li>Timely claim handling—no backlog, reduced phone calls, increased customer satisfaction </li></ul><ul><li>Individual development—time for training, for learning through doing </li></ul><ul><li>Staffing model—earned staff per projected sales </li></ul>
  22. 22. More win win <ul><li>Formal training for new hires to reduce the new hire/productivity lag </li></ul><ul><li>Metrics and measures for evenly calibrated and fair individual performance assessment </li></ul><ul><li>Ongoing feedback and coaching for personal development </li></ul><ul><li>Opportunity to try new roles </li></ul>
  23. 23. March of the Penguins <ul><li>The Penguins make our job look easy </li></ul><ul><li>Solutions: </li></ul>