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Reduce medical claims leakage & improve claims management
Enable medical necessity reviews of workers' compensation claims at scale.
Create a recommended plan for treatment by incorporating artificial intelligence with evidence-based guidelines
Cognizant Workers Compensation Care Analysis generates a recommended treatment plan for each claim, so your organization can drive medical cost containment at scale. It’s an easy-to-deploy, business process as-a-service solution that automates and expands medical necessity reviews across your claim volume.
Applying artificial intelligence and incorporating evidence-based guidelines, the solution automatically creates a recommended plan for treatment on each claim and compares it to the actual treatment performed. When the system identifies discrepancies, claims are reviewed by a team of clinical professionals. This streamlines the medical necessity review process and reduces complexity, resulting in better treatment for injured employees and lower costs for carriers.
Workers Compensation Care Analysis
Identify non-essential, non-compensable medical services with a common framework based on existing and emerging medical evidence for all types of workers’ comp claims.
LEARN MOREINSURANCE
Automation and Expertise Plug the Leaks in Medical Claims Costs
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The Challenge
Medical benefits associated with workers’ compensation claims have escalated dramatically, more than tripling since 2003. For one global insurance carrier, excessive or unnecessary treatment associated with these claims resulted in medical claims leakage of a staggering 7% to 9% annually.
The company needed a strategic solution as traditional cost containment strategies, such as bill review, utilization review and nurse case management, were failing to address the leakage. The company partnered with Cognizant to find a solution.
Our Approach
We helped the insurer implement Cognizant Workers Compensation Care Analysis, a customizable treatment plan engine for automating claim processing, and combined it with trained clinical services staff to review claims requiring intervention.
This “medical necessity review as a service” capability enables the establishment of injury-specific treatment plans. It also validates clinical activities against those plans, automatically reviews every claim and routes exceptions to trained registered nurses for review.
Our Approach
We helped the insurer implement Cognizant Optima MedWise™, a customizable treatment plan engine for automating claim processing, and combined it with trained clinical services staff to review claims requiring intervention.
This “medical necessity review as a service” capability enables the establishment of injury-specific treatment plans. It also validates clinical activities against those plans, automatically reviews every claim and routes exceptions to trained registered nurses for review.
Routing Reviews to Clinical Experts Optimizes Claims Handling
Integrating medical necessity review into the carrier’s claims process helps facilitate medical care for injured workers, achieve better outcomes and reduce medical costs without increasing claims allocated to loss adjustment expenses.
$508 million
in excessive or unnecessary claims identified in three years
~$192 million
in savings since going live
40%
of medical bills auto-adjudicated
Accelerated pathways to digital transformation in insurance
IDC observes that many innovative businesses are considering SaaS offerings as they help avoid the need for large on premise solutions, complex integration requirements, or expensive and time-consuming customizations. Industry-specific or vertical SaaS offerings are applicable when an insurance carrier wants to bring a specific service to the market quickly with greater cost efficiency, usability, and flexibility.
READ WHITEPAPEROUR PERSPECTIVES
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