As Vice President of Subrogation Operations for Discovery Health Partners, Heather is responsible for directing the company’s Subrogation organization and driving continuous improvement in how the company delivers subrogation services for its clients.
It takes people with a unique mix of skills and experience to successfully handle complex healthcare subrogation matters involving third-party payers. Health plans that don’t have the right professional resources to identify and pursue recovery opportunities run the risk of leaving millions on the table.
Recruiting and retaining top-tier subrogation talent can be challenging but well worth the effort. Here are some insights and advice on finding the right subrogation staff, based on a recent survey of healthcare subrogation experts.
1. Subrogation experience is important but not critical
When it comes to prior work experience, front-line professionals agree that 1-4 years of experience provides a firm foundation.
What you might find surprising is that past subrogation experience is not the most important hiring criteria. Candidates with experience in related fields such as legal, claims, property and casualty, or medical coding typically have what it takes to review and understand complex medical claims.
Subrogation professionals also agree that regardless of industry affiliations, candidates should have top-notch organizational, multi-tasking, customer service, and communication skills. Additionally, the most successful subrogation specialists are good investigators, analysts, and critical thinkers who can navigate the “gray areas” to solve problems creatively. Solid relationship-building skills and a positive attitude are also must-haves to help subrogation professionals successfully negotiate for their share of limited recovery dollars.
2. Cast a wider net
In today’s tight job market, companies may have to look outside their industries and geographic regions to find top talent. Thanks to technology, more healthcare companies can offer remote work opportunities that will attract the best and brightest from across the country.
The medical and legal fields are good sources for high-quality candidates with transferable skills, since they already understand concepts used in subrogation. Often, healthcare companies can find new talent for entry-level positions at college career fairs. Look for students with backgrounds in legal studies, paralegal, and political science.
Law firms are filled with professionals who can easily apply their personal injury, class action, contracts, property and casualty, health, disability, and reinsurance claims experience to a career in healthcare subrogation. Insurance companies are also a good source of employees who already speak legalese and have mastered case management, handling multiple files at once, and reviewing medical claims.
3. Look beyond the resume
Once you find qualified candidates, you can use pre-screening tests and assessments as well as interviews to determine if someone will be a good fit for your organization. A multitude of online test sites offer customizable tools to measure everything from aptitude and attitude to role-specific knowledge and skills.
Assessments are good predictors of performance and offer insights to a candidate’s likelihood of job success as well as cultural indicators, such as honesty, discipline, and reliability. They can also help you make unbiased employment decisions based on quantifiable data.
Behavioral or problem-solving interviews that examine candidates’ past experiences or present real or simulated problems to solve will reveal insights into candidates’ thought processes, problem-solving skills, and ability to think clearly under pressure. Meanwhile, planned or structured interviews that present the same set of questions to everyone help level the playing field and call out the clear winners.
4. Set employees up for success
Congratulations! After a lot of time and effort, you found the right talent. So how can you keep them with you for the long haul?
Training is a good start to set new hires up for success and help more experienced employees advance their careers. Classroom training can cover in-house case management systems, procedures, and other basics. Side-by-side shadowing provides more in-depth exposure to practical applications. And mentoring is a great way for employees to get immediate feedback and learn tips and tricks of the trade.
5. Follow the leaders
Front-line subrogation specialists say that culture is a key to employee satisfaction. Adobe, Google, Southwest Airlines, and other highly sought-after employers have turned their culture into a competitive advantage by offering a combination of work, lifestyle, and monetary rewards. Challenging work assignments; empowering employees to go the extra mile to help customers; and perks like flexible working hours, on-site gyms, and even dog-friendly workplaces are incentives that the companies use to encourage loyalty.
Don’t forget rewards and recognition. Many subrogation associates see themselves as having a long-term career in the industry. Those who have a defined career path and feel valued are more likely to spend their career with you. Money can be a good motivator, but sometimes all it takes is a shout-out on the company website or positive feedback from an executive to encourage and inspire employee loyalty.
Collaborate with the experts
Even health plans with the best subrogation specialists can benefit from Discovery Health Partners’ deep expertise, advanced technologies, and data-driven approach. Find out how we can help health plans improve their recovery efforts on our Subrogation solutions page.
Heather Rodemann5 keys to hiring and keeping top-notch subrogation talent
Healthcare subrogation can be terrifying! Health plans are “afraid…very afraid” of what high costs and low settlements do to their bottom line. They’re frightened of member backlash about questionnaires and phone calls asking for details about injuries they’ve suffered.
Let’s face it, we’ve all endured subrogation nightmares that keep us awake at night feeling anxious and dreading the dark. From case overload and staffing issues to non-responders and negotiation horrors, it seems that something scary is always lurking, waiting to throw us off track.
In this article (using more than a bit of tongue-in-cheek nods to some famous spooky movies), we’ll explore typical subrogation horrors and how advances in data and technology are helping us overcome the fright and emerge victorious.
What happens when case identification goes overboard?
Does your subrogation rely on broad case identification parameters? Do all identified cases flow into the investigation process? Do you find your team being eaten alive by case inventory backlog? If you said yes to these questions, “you’re gonna need a bigger boat.”
It has long been common practice to attempt to maximize subrogation recoveries by casting a “wide net” to identify suspect cases – often based mainly on diagnostic codes. Yet these loose identification standards produce too many false positives (unrecoverable cases), which when they make their way into the investigative stage, can drown recovery teams in excess work. The team either has to grow or it becomes overwhelmed and backlogs start to build up. In either case, it costs plans time and money without producing proportionately greater recoveries.
Meanwhile, the investigation of false positives can lead to unnecessary member outreach in the form of calls and questionnaires, which can confuse and frustrate members needlessly. With fierce competition among payers today, none can afford member abrasion.
Best practice is to avoid over-identifying subrogation cases. It’s a delicate balance between identifying too many cases, resulting in false positives, and identifying too few cases, resulting in missed opportunities.
Three trends shaping the future of subrogation
Like the transformation from a drab landscape to a technicolor dreamscape, the last decade has seen dramatic advances in technology that can transform the subrogation operation from a dreary manual process to one driven by advanced technologies and automation.
From cloud-based storage and applications to data proliferation and predictive analytics, we now have faster, cheaper access to technology that can help us:
Leverage more sources of data from multiple internal and external sources
Identify subrogation-worthy cases faster and more accurately
Make pre-payment decisions about other party liability
Prioritize cases for investigation by scoring them based on multiple factors
Match cases to team members according to various factors such as workload and skill
Manage communications, including generating outgoing letters and uploading incoming letters
Capture information about relevant parties, including insurers, providers, and attorneys
Track and report on case progress for your whole inventory
To operate more efficiently, reduce costs, and improve recoveries, health plans should consider three trends that are taking shape in subrogation operations, both within health plans and subrogation vendors.
“They’re heeere!” More data sources, that is!
It may sometimes feel like a terrifying spirit lurking within your walls, but don’t fear data! It’s your biggest asset and it’s all around you. With the abundance of internal and external data sources available today, you should be using all possible investigative tools to more accurately identify and investigate subrogation cases that have recovery potential.
First, it’s critical to ensure you’re maximizing all the data currently available to you. Then seek supplemental external data sources that can fill in context without member contact. Finally, use all this data to learn from past experiences and continuously improve your processes.
Traditional data sources contain valuable information
Traditionally, subrogation cases are identified based on diagnostic data from the member’s claim file. While this is an appropriate starting point, it’s important to go beyond diagnosis codes. By analyzing them along with demographic information, procedure codes, revenue codes, and other data elements, you can identify the relationships that lead to recoveries and that allow you to prioritize recovery efforts.
And when you continuously analyze these codes in connection with varying demographics (age, location, presence of other medical conditions) compared against the data on recoveries achieved, you can constantly refine which combinations are more likely than not to result in a recovery.
External data adds context
Meanwhile, external sources of data about motor vehicle accidents, liability, litigation, and workers’ compensation can provide valuable insight about claims, which can speed up case identification and investigation.
In recent years, these types of third-party data have become increasingly affordable and are available fast and electronically, so they can easily be incorporated into your systems. Data such as court documents, police reports, ambulance run reports, and litigation databases is extremely useful in the decision to open a case. It reduces your reliance on Incident Questionnaires and may allow you to sidestep member outreach altogether.
Additionally, some data sources can point to unique subrogation cases, such as malpractice or mass tort, which can be difficult to identify through normal data mining algorithms. In this case, eligibility information can be matched up to court case databases. As an example, a cancer diagnosis code does not necessarily indicate an injury, but it could be the result of negligence on the part of a company that has been named in a mass tort case.
By now, you may be thinking “easier said than done.” Maybe not. Read on to learn how Trend #2 enables plans to access and integrate internal and external data sources to simplify case identification as well as investigation and recovery.
“It’s alive! It’s alive!” On-demand applications bring sluggish subrogation operations to life
Software-as-a-service applications are alive! On-demand subrogation software offers web-based access to data integration, case management, forecasting, and reporting. These applications allow you to integrate multiple data sources (without relying on internal IT) and leverage built-in analytics to identify cases more accurately. Case management features guide investigation and recovery processes with powerful tools such as diaries, contact databases, and letter generation engines.
These applications allow you to see the big picture across your subrogation operation. They maintain an ongoing record of all activity and correspondence for each case so that anyone with proper access can see the status of the case and any activity associated with it. If you’re able to use the application internally and extend access to your subrogation vendors, you’ll be able to measure performance across all delivery teams. This can provide valuable insight about worker productivity, process effectiveness, and overall financial performance.
Increasingly, application vendors are incorporating machine learning (a form of artificial intelligence) into their products. What this means is that over time, the system will continuously learn from the data and use what it learns to refine identification algorithms.
“Whatever you do, don’t fall asleep.” Prepayment cost avoidance and other tips to be proactive
Avoid subrogation nightmares with pre-payment solutions
What better way is there to maximize your bottom line than to know in advance of paying a claim that it’s another party’s responsibility?
Traditional subrogation models seek to recover funds after a payment on the claim has already occurred. But pre-payment subrogation decisions are now a real possibility, thanks to the availability of data and the technology that quickly integrates and analyzes it for us.
It makes sense for plans to begin exploring pre-payment capabilities, as it allows them to avoid 100% of the claim cost as well as the cost to recover after payment has been made. By quickly analyzing multiple types and sources of data, it is possible to determine much more quickly whether a) an injury is the result of another party’s fault and b) a claim has been filed by another carrier that would have primary responsibility for payment.
The key is to have the data and technology in place. Whether you are graced with a supportive IT team that develops these capabilities with you, or you acquire the applications externally, it’s critical to have fast access to data from multiple systems.
When implementing a pre-payment subrogation strategy, think strategically, review state requirements and your policy language. There are nuances to pre-payment but by engaging with your IT, legal and contracting teams, it can be successful. Additionally, keep in mind that pre-payment cost avoidance should be coupled with post-payment recovery for a holistic approach that follows the transaction through the whole lifecycle. Despite the efforts to acquire the right types of data, you won’t always get what you need fast enough for a pre-payment decision. Traditional post-payment subrogation augments pre-payment and serves as a safety net to catch any claims that you aren’t able to make a determination on within timely filing limits. Some erroneous payments will continue to be made, requiring post-payment evaluation.
Be alert for opportunities to optimize post-payment processes
The term “time is money” is very relevant to subrogation. The faster a case is handled, the better the plan’s chances are of maximizing the settlement. Therefore, it’s critical to be proactive throughout the post-payment subrogation process. Again, data and technology are key to making more informed decisions and automating complex tasks. Below are some tips:
Prioritize cases. Dollar value tends to be the most used metric for prioritization, but it shouldn’t be used alone. As mentioned earlier, multiple pieces of data can be used to determine recoverability, so teams can focus first on those cases that are more likely to settle.
Align case complexity with skills. When the most complex cases are assigned to the most skilled resources, they are likely to reach a settlement faster. This requires a definition of the elements of case complexity, as well as a method of evaluating skill levels.
Legal oversight. Legal resources should be engaged during the settlement phase of a subrogation case to aggressively pursue optimal recovery for the health plan. Though settlement is typically the shortest phase in a subrogation case, it’s also the most complex. With limited dollars available, legal negotiations must be articulate and based on a strong understanding of the plan’s rights.
Track and measure consistently. Measurement of subrogation performance is critical to knowing what works and where to make improvements. Plans should insist upon robust reporting and analytics across their subrogation inventory to quantify recovery efforts, view real-time and historical case data, forecast recoveries, and get regular reimbursement reports.
Causes of subrogation elation
Besides our references to horror movies, the common theme here is that data and technology are helping subrogation organizations maximize financial results for their plans more effectively than ever. Now is the time to take a fresh look at the tools and techniques used to identify, investigate, and settle third-party liability cases. Work with your IT organization, talk to your vendors, and evaluate the subrogation software available today. Our white paper on Transforming subrogation operations with data, technology, and analytics explores how newer technologies are making it more possible than ever to narrow the focus on subrogatable cases, minimize member contact, shorten time to settlement, and maximize recoveries.
Heather RodemannHow to wake up from subrogation nightmares
For many health plans, the challenges associated with subrogation―the process of recovering healthcare claim payments that are a third-party’s responsibility―are significant. Outdated identification methods, potential member abrasion, slow validation processes, and marginal settlement rates all impact your ability to appropriately contain and recover costs.
How can you overcome these challenges and maximize recoveries in less time and at a lower cost? Software-as-a-Service (SaaS) applications are a way to enhance your subrogation programs and recoveries. Plans are finding that the combined power of transformative technology and in-house expertise facilitates a more effective, data-driven approach for finding and validating recovery opportunities with minimal member abrasion.
With this in mind, here are three simple but powerful ways SaaS solutions can help you optimize your subrogation operations:
#1: Make in-house recovery management more efficient and insightful
The power of automation allows health plans to do more with less. Built-in algorithms, advanced data-mining techniques, and machine learning work to effortlessly manage cases and shorten the information gathering process. Reporting and analysis give instant and sharable views into recovery efforts. Combine these solutions with user-defined customization options that can be tailored to your needs, and the once burdensome task of subrogation becomes a breeze.
#2: Gain accessible, easy-to-use, highly scalable, and secure solutions
With SaaS, there’s no need for rigorous installs or startups. The system can scale drastically and on-demand, depending on your organization’s needs. Most importantly, the security and fail-safe measures in place not only guarantee continued operations in an emergency, but also consistently ensure that HIPAA and HITRUST CSF® certification requirements are met.
#3: Do more at a lower cost
With the advent of cloud technology, SaaS offers a significant boost to the bottom line for any business. Every application can be accessed from a simple desktop, and processes have been streamlined to make it as painless as possible. Regular, non-disruptive system enhancements work to improve your solutions as well, so your recovery efforts—and your business—continually evolve without interruption.
In a highly competitive marketplace where claims accuracy and cost containment are paramount, SaaS applications can empower your plan with improved efficiencies and productivity―facilitating more accurate payment decisions and generating greater recoveries.
When it comes to getting better results from subrogation, forget everything you ever learned in kindergarten! Being unfair is…well, unfair; ignoring people is bad; and being pushy is rude.
But adopting a few “bad” habits actually can make your subrogation program stronger to drive better financial results and member feedback.
1. Be unfair
Not all subrogation cases are equal, so let’s not treat them that way. Some cases are worthy of more time and energy than others, so let’s find new and better ways to identify the right cases and use the most advanced methods to pursue them.
First, you have to be as certain as possible that a case has subrogation potential and this starts with the identification phase of your subrogation process.
For too long, the practice was to cast a wide net when looking for cases to subrogate. Anything that looked like a car accident or a slip-and-fall case ended up in the “verification” bucket. The problem with this “wide net” approach is that it funnels too many false positives into the process. Devoting time and resources to a case that has no recovery potential ties up your staff (which costs you time and money) and creates undue stress on members.
The last decade has seen advances in information science and technology that have allowed subrogators to more precisely identify cases that actually have third-party liability and can be expected to reach a settlement.
You can now mine claims data for details such as diagnosis codes and demographic data that signal a subrogatable case. In fact, ICD-10, which came out in 2015, has been beneficial for companies using data mining to zero in on claims with greater likelihood of having subrogation potential. Many health plans and vendors have adopted these techniques, which have allowed them to reduce false positives so they can use resources more efficiently and cost-effectively, while improving settlement ratios.
Recent years have seen the most aggressive health plans and vendors (including yours truly) begin to experiment with technologies that fall into the category of artificial intelligence, machine learning, and predictive analytics.
These emerging technologies allow us to build upon the improvements of the last decade by learning from subrogation results and automatically applying those learnings back into the case identification algorithms to become even more precise.
2. Ignore your members
Well, not really. But as you pursue the big business of subrogation for your health plan, keep an even bigger focus on your members’ experience. Remember that your members come first above all.
It has become clear to all of us in this business that we need to find more ways to verify the causes of injury and rely less on calling and mailing members repeatedly. The first line of defense for your members is the identification process (described in #1 above), which allows you to more accurately identify cases that actually have third-party liability. With this smaller net, you minimize false positives, which as a matter of course, reduces unnecessary outreach to those members.
Additionally, you can take advantage of external liability databases and other third-party data services to augment your detection methods and further minimize member outreach. One use case for this type of service is medical malpractice and personal injury claims, which can be difficult to find using traditional data mining techniques. These techniques can shorten the lifecycle of subrogation cases by as much as 90 days, while minimizing member outreach.
3. Be pushy
The previous two subrogation bad habits lend themselves to the third, which is to be pushy. When we’re aggressive about accurately and quickly identifying and verifying subrogation cases, we increase our chances of not only reaching settlement more quickly, but also reaching a settlement that is agreeable to us and/or our clients. How, you ask?
One way to get more aggressive is to prioritize cases by dollar values and “push” them to staff accordingly. Obviously, a case totaling $450,000 in claims demands more attention and resources than one totaling $4,000 in claims. Yet traditionally, all cases ended up in the same pile to be worked top to bottom. In subrogation, time is money.
The faster you act on a case, the better your chances of reaching a desirable settlement. But the faster cases pile up, and the more overwhelmed the team gets, the more this idea falls by the wayside.
Case management technologies can automatically drive prioritization methods throughout your subrogation process based on rules you define. As a result, you can get the timeliest and costliest cases pushed to the top.
Similarly, case management queues can assign specific cases to recovery specialists most suited to characteristics of the case. For example, if you can identify which team members are best at negotiating with difficult attorneys, then you can automatically push cases to those specialists.
Engage legal resources at the right time
Once you make it to the settlement phase of a subrogation case, it’s important to engage with your legal resources, whether internal or external, to aggressively pursue optimal recovery for the health plan.
Though settlement is typically the shortest phase in a subrogation case, it’s also the trickiest and most involved because it’s when you start talking about limited dollars available, you have to be articulate in legal arguments, you must have a strong understanding of the plan’s rights, and you must be able to aggressively negotiate to recoup dollars on behalf of the plan.
Subrogation lawyers and paralegals who are trained to manage these types of negotiations can navigate this complicated phase to quickly optimize your settlements.
Consider subrogation prepay cost avoidance
Health plans are showing a growing interest in identifying third-party liability before paying a claim. As health plans become increasingly adept at data integration for mining and analytics (either internally or through their vendors) they have more tools to inform pre-payment decisions.
If a plan is able to coordinate a third-party liability claim with a primary payer, it can avoid the cost without engaging in subrogation methods. Due to time constraints, pre-pay subrogation may prove to be more member intensive, requiring direct outreach to identify if there is another recovery source.
In the case of subrogation, as in most payment integrity functions, pre-pay cost avoidance has to be balanced with post-pay recovery. It’s never all or nothing. Even if the decision is to pay a claim because it appears that there is no liability or no other coverage available, the claim can be pended for potential post-pay subrogation.
Now is the time for subrogators to take a fresh look at the tools and techniques they use to identify, investigate, and settle third-party liability cases. Technology-enabled subrogation is the way to go, and fortunately for everyone, newer technologies are making it more possible than ever to narrow the focus on subrogatable cases, minimize member contact, shorten time to settlement, and maximize recoveries.