8. Compliance and Regulatory Mandates
Remaining compliant in the insurance and healthcare industries is not an easy task. Today's
claims organizations are flooded with increasing volumes of data. With the ongoing
complexity and ever-changing regulations on the local, state, and federal level – coupled
with the steep fines and penalties for non-compliance -- the process can be daunting.
For instance, there are thousands of forms across all jurisdictions that need to be completed,
filed, and submitted at different points in the claims process. Deadlines differ depending on
the type of form and state requirement, and these need to be kept current with changes and
updates. Some policies – like workers' compensation – are even more complex. Payments
made to injured workers often vary state-by-state. Rates are frequently changed or updated,
and the calculations can be cumbersome. And it is critical for claims organizations to maintain
accuracy and to respond in a timely manner.
The Complexity of Workers' Compensation
Compounding the workers' compensation paradigm is the rise of Electronic Data
Interchange (EDI) reporting. More states are adopting the International Association
of Industrial Accident Boards and Commissions (IAIABC) electronic reporting of two
key records – First Report of Injury (FROI) and Subsequent Report of Injury (SROI).
While the IAIABC sets the standard, each state has its own rules and regulations
regarding the timing and sequence of submissions. Incorrect transmissions can
result in delays, re-submission of claims, and/or substantial fines.
On the bright side, new technologies are helping insurers to keep up to date (and compliant)
with these ever-changing state-specific rates and regulations without compromising claims
process or workflow efficiencies. Automated processes are ensuring improved accuracy,
streamlined reporting, and a reduction in administrative bottlenecks and costs.
Does the vendor offer a dedicated compliance department?
Does the vendor maintain all forms and documents?
Does the vendor support EDI reporting?
Can the vendor provide real-time data feedback to the client (i.e., flagging missing or
incorrect data)?
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Questions to Ask
