Identifying Failing Claims and Driving Efficiency

Introduction

Claims examiners are the cornerstone of any successful workers’ compensation program. They handle complex cases, meet deadlines, and ensure timely benefits while navigating rising workloads and high turnover rates.

With too many tasks and too little time, examiners often struggle to prioritize effectively, leading to delays, increased costs, and dissatisfied stakeholders.

By leveraging advanced technology and actionable insights, Plethy empowers examiners to prioritize their efforts, focusing on injured workers who need the most support while streamlining processes for those on track to recovery.

This narrative explores how Plethy can help claims examiners reclaim control, improve efficiency, and drive better outcomes for everyone involved.

The first step to improvement is recognizing the warning signs of inefficiency. A failing claims administration system often exhibits several red flags, including:

Missed Deadlines and Delays:

Examiners overwhelmed by excessive caseloads need help promptly investigate claims, communicate with stakeholders, and meet regulatory deadlines.

Poor Communication Practices:

Inadequate responsiveness and a lack of empathy in interactions with injured workers fuel frustration, mistrust, and unnecessary litigation.

Inefficient benefit delivery:

Delayed treatment authorizations, failure to pursue subrogation, and poorly managed litigation costs drive up expenses.

Growing Pending Inventory:

Backlogged claims and delayed settlements signal inefficiency and resource strain, leading to higher litigation risks.

Inadequate Handling of Complex Claims:

Without tools to identify and address complex cases early, examiners face preventable escalations and prolonged resolutions.

Burnout and High Turnover:

The relentless workload and lack of support lead to examiner burnout, further exacerbating inefficiencies in the system.

Plethy Helps Examiners Prioritize Their Work

Plethy reshapes claims handling by providing tools that simplify decision-making, streamline processes, and prioritize intervention where it matters most.

1. Early Detection of At-Risk Claims

Plethy’s advanced analytics enable examiners to quickly identify claims requiring urgent attention. The program monitors engagement levels, compliance with treatment plans, and psychological factors, flagging cases that may be at risk for delayed recovery or litigation.

Example: An injured worker failing to complete prescribed at- home therapy due to a life-event is highlighted in reports, prompting the examiner to intervene early and provide support before the situation worsens.

2. Monitoring Worker Engagement

Engaged workers are more likely to recover quickly and require less examiner oversight. Plethy tracks workers’ activity, such as home exercises, pain, and mood, to help identify those who may need additional encouragement or support resources.

Benefit: By focusing on disengaged workers, examiners can allocate their limited time effectively, improving outcomes and reducing overall workload.

3. Streamlined Communication Tools

Plethy enhances communication with injured workers through coaching and automated reminders. Bilingual support ensures that language barriers do not hinder engagement.

Feature: Examiners receive recovery updates on worker progress, eliminating the need for constant follow-ups and manual

4. Data-Driven Insights for Decision-Making

Plethy’s dashboard provides examiners with actionable data to guide their decisions. Trends in home exercise adherence, mood, and pain are displayed intuitively, helping examiners prioritize tasks.

Impact: Examiners can identify patterns and intervene strategically, optimizing outcomes.

5. Reducing Administrative Burden

By automating routine tasks, such as tracking treatment compliance and generating status updates, Plethy frees up examiners to focus on complex cases requiring human expertise.

Example: Automated alerts for missed milestones in treatment plans allow examiners to address potential issues without manually combing through files.

The Role of Engagement in Claims Success

Plethy recognizes that engaged workers demand less from the claims system. By fostering engagement through empathetic coaching and data tracking, Plethy helps injured workers stay on track.

A Proactive Approach to Claims Handling

By leveraging Plethy’s tools, claims examiners can proactively address inefficiencies and focus their efforts where they will have the most significant impact.

• • Prioritize Early Intervention: Identify at-risk workers and intervene before minor issues escalate.
  • Enhance Communication: Use Plethy’s platform to keep all stakeholders informed and engaged.
  • Support Examiner Well-Being: By reducing administrative burden and streamlining information, Plethy helps prevent burnout and turnover among claims examiners.

Conclusion

Claims examiners face an uphill battle, managing heavy caseloads while trying to provide timely, practical support for injured workers. Plethy offers a lifeline, equipping examiners with the tools they need to prioritize their activities, reduce inefficiencies, and improve outcomes for injured workers and employers alike.

With Plethy, the cart stays firmly on the road—ensuring smooth operations, happier stakeholders, and a more efficient claims administration process.