See the Forest and the Trees
RMIS and Claims Management Systems in Your Organization
By Terry Preece
A simple explanation to define the complex functionality of a RMIS is to use the analogy of not seeing the forest for the trees. With a claims management system the capabilities are focused on providing detailed information on one particular claim, or tree in the forest. In contrast, a RMIS provides the capability to look at a claims operation, or the forest, and analyze its characteristics and patterns as a whole.
The risk manager for insured and self-insured organizations would be the typical user of a RMIS. It is beneficial to the following lines of business: auto liability, auto physical damage, workers’ compensation, products liability and general liability. Though these are the typical lines that use a RMIS, they are not the only lines that could benefit from implementing one. In companies where a risk manager is not present, the RMIS can prove even more valuable. Executives who oversee claim costs and risk for their company can utilize the system to efficiently report on all data that is available. This risk data might spread across various TPAs, carriers and also internal systems used to manage certain claims. Without a RMIS system, this information could only be obtained separately from each individual source, then manually combined in order to provide some semblance of a company-wide risk profile. Combined information may not provide the most current and accurate information and is prone to errors.
In contrast to a RMIS, a claims management system focuses on a single claim, or tree, rather than the whole forest. A claim is handled with great detail as a single entity. A claims management system is the workplace of the adjuster and is used to manage claims and all related tasks required to process them. This includes recording all the additional information about the claim and claimant that might be missing from the First Report of Injury, documenting all ongoing communication, making payments by producing checks, and providing correspondence to assist with communication to the claimant. Within the system is the intricate detail on litigation, medical providers, payments, claim contacts (e.g. witnesses, attorneys, and vendors) and thousands of other data elements that are required in a claim file.
Almost anyone tasked with the responsibility of managing claims should be using a claims management system. Claims management system users might be the adjuster at a self-insured company, or the adjuster at the company that handles all claims under a large deductible. Other users might be risk management personnel who have some claims oversight in addition to the claims management done by their carrier or TPA. Claims management systems are used in virtually all lines of business.
As every company has unique requirements, it is recommended that each establish a set of tailored criteria to use when evaluating potential RMIS or claims management system vendors. When developing criteria, a few universal qualifiers may include:
- Do they have a good, solid reputation in the industry? Checking references is always wise.
- Do they have experience in the industry?
- Can they get the system up and running in a reasonable timeframe?
- Are they flexible and willing to work with you to find a solution that fits your needs?
- Do they offer the functionality you require? It may be helpful to make a functionality checklist before you start reviewing vendors. Some potential items to have on the list may include:
- Data consolidation – a RMIS’ value is highly compromised if data from all sources isn’t included
- Standard set of reports including graphs and charts
- Ad-hoc query capabilities
- Diary and note oversight functionality
- Ability to aggregate and code the data correctly to a single standard
- Basic claims lookup
- Ability to export data in a variety of formats.
Check the following boxes that are similar to your organization’s needs:
- Is your organization’s claim data divided among different locations (e.g. in-house claims, carrier, previous carrier, TPAs, previous TPAs, etc.)?
- Do you need to consolidate data in order to report on claims?
- Do you find your current claims management reporting capabilities inflexible?
- Does your organization manage claims or assist with managing claims?
- Do you need to make and record payments on claims?
- Do you need FROI, SROI, EDI, ISO, OSHA, bill review, document imaging, attachments or business rules?
By implementing a claims management system, accuracy and efficiency is improved. Combining that system with a RMIS ensures that the most accurate data is used to examine historical trends. It also helps ensure that risk is mitigated and planning for the company’s future is founded on fact.