LET ME FILL THE BLANKS
Completed a _____ to determine missing information.
Completed a first look claim assessment to determine missing information.
Timely and Accurate Decisions
You’re now in a position to make a timely and accurate claim decision , which will likely
have a significant impact on the employee’s quality of life and reinforce that the employer’s
decision to place their trust in your organization was the right one.
Interpreting means “to give or provide the meaning of.” You do this when interpreting the meaning of plan provisions. For example, you interpret the meaning of “material and substantial” when deciding if a duty or task meets that definition. Interpretation relies heavily on experience and knowledge.
INTERPRETING
Efficient and Timely Decisions
You will make timely decisions. You will pursue only information that is on the critical path to your decision, and you will make the decision once you receive that information. You will be able to delineate information needed now for a decision versus information that may be useful later in the life of the claim. You will not hold decisions awaiting information needed for the future.
Established the ____________ of the occupation
Established the material and substantial duties of the occupation
Assessed the employee's _______ to ensure_________.
Assessed the employee's contractual eligibility to ensure insurance coverage
Critical thinking and workflow processing
Managing claims requires a balance of two contrasting skills: critical thinking and
workflow processing . An organization’s defined process steps provide the broad
framework that’s required for consistency and predictability, but critical thinking actually
defines the content and quality of the actions and decisions that build upon that framework.
Processes across the industry are very similar, yet the differentiator between good and
great claim management is the quality of thought that drives claim strategies and tactical
activities.
This involves a systematic examination and evaluation of data or information by breaking it into its component parts. For example, you are analyzing when you examine the individual parts of the definition of disability (sickness or injury, material and substantial duties, loss of income) when evaluating a claim.
ANALYZING
Well Developed Action Plan
You are consciously considering what each claim needs uniquely and developing a strategy supported by tactical action plans. Below is additional detail on the components of a claim action plan: You have conceptualized the key issues that need to be resolved and/or the key questions that need to be answered in order to make a decision on the claim. You have analyzed the most effective way of obtaining the information needed to resolve the issue or answer the question .
Leveraged the _________ to provide you with a grounding in the medical diagnosis
Leveraged the MDGuidelines tool to provide you with a grounding in the medical diagnosis
Established the _________.
Established the date of disability.
Accurate identification and execution of overall claim approaches
The ultimate measure of your skill as a DCM is how effectively you identify and execute
overall claim approaches that result in timely and high quality decisions. The approach you
take to making decisions will have a great impact on their accuracy and effectiveness,
beginning with the initial STD claim determination.
This is the combining of disparate data elements into a cohesive whole(connecting the dots). You do this when you bring together your findings from the analysis of the individual components of the definition of disability to determine if the claimant meets the overall definition of disability.
SYNTHESIZING
Well Considered Decisions
When information is received, you apply a discipline of critical thinking to reach a conclusion. You may seek expert resources to assist you, but you are still accountable for the ultimate conclusion and decision.
Utilized your _________ to validate the Attending Physician’s stated restrictions and limitations
Utilized your clinician resources to validate the Attending Physician’s stated restrictions and limitations
Engaged the _______ to obtain missing information and/or clarification on information provided.
Engaged the employer to obtain missing information and/or clarification on information provided.
HIGH LEVEL WORKFLOW OVERVIEW
The formal consideration of the information you’ve gathered and evaluated is an important milestone in the life cycle of an STD claim.
You conceptualize when you form an idea or principle in your mind. You do this when you imagine the claimant’s level of functional capacity based on information you have gathered. You form a picture in your mind of the claimant’s impairment and functional capacity.
CONCEPTUALIZING
Appropriate Application of Judgment
You are comfortable bypassing process if it doesn’t advance the evaluation of the claim. The focus is on outcomes, not process.
•Quality is defined as achieving the right outcomes, not following the right process.
•Process is viewed as a tool to achieve outcomes, not an outcome in itself.
Engaged the ________ to understand his/her _________ on how the medical condition impacts his/her ability to ______.
Engaged the claimant to understand his/her perspective on how the medical condition impacts his/her ability to work
Assessed __________ to determine the employee’s functional capacity
Assessed medical information to determine the employee’s functional capacity.
JUDGEMENT
The ability to make considered decisions or come to sensible conclusions.
When you evaluate, you determine the significance or value of something. You do this when deciding the significance of medical records you receive as part of your evaluation. Some information or records you consider important and relevant, while you deem other information incidental and insignificant to your decision making.
EVALUATING
Decision Tree
Components of Initial STD Claim Decision
Initial Decision - Approve - Determine Payment Duration - Create Strategic Plan
Initial Decision - Deny
WHAT ARE THE KEY ELEMENTS OF DECISION MAKING
Analyzing
Synthesizing
Conceptualizing
Evaluating
Interpreting