Applying artificial intelligence technology should not be intended to replace the human expertise in the worker’s compensation claims experience. It should amplify it. When deployed well, AI can strike the right high-tech, high-touch balance, allowing the company to harness AI’s efficiency while delivering the empathetic approach that must define high-quality claims handling.
AI is transforming almost every industry that uses technology. The third-party administration industry is no exception. For providers, carriers, clients and claimants, TPA is on the cusp of dramatic innovation, especially as technology is developed and deployed thoughtfully with a vision of improving efficiency and enhancing the experience of all involved.
TPAs handle millions of claims each year. So, it might seem like a no-brainer for TPAs to automate as many of the processes as possible. Yet here’s the challenge: claims adjusters interact not just with claims data, but with human claimants, as well as supervisors, administrators, doctors, nurses, lawyers, clients, carriers and others. Each involved in these engagements expects a personalized process and outcome. It’s up to the TPA to deliver on that assumption.
The beauty of AI and machine learning is they analyze data and draw inferences from current and previous encounters that allow it to learn and adapt without explicit instructions. As we incorporate into our efforts AI and machine learning, how do we ensure the business maintains its humanity? How do we make certain high-tech solutions don’t interfere with the high-touch approach we’ve always provided?
In the workers’ compensation claims process, clients expect claims-handling to help meet one or more of these four high-level objectives:
- Maintain quality standards of the clients, regulators and/or carriers;
- Achieve optimal outcomes, such as loss cost or outcomes or disability duration;
- Ensure a good user-experience for the client’s employees and their risk management team, as well as for the TPA’s adjusters and nurses who serve as extensions of their team; and
- Ultimately, to optimize efficiency
The multiple stakeholders in the claims industry each brings overlapping but distinct needs, some of which may even conflict. This leaves the TPA to match processes with acceptable outcomes. Technology has long been at the center of this complex business, and it is tempting to take one of two extreme approaches. One could be the over-standardization of the process for maximum efficiency. The other is to use technology solely for data management, while leaving claims handlers to navigate an increasingly complex universe unaided. The goal must be to keep professionals deeply involved in each engagement to ensure clients are well served.
A balanced approach — one that honors all the human participants while leveraging AI and other advanced technologies to their highest and best use — can optimize and harmoniously deliver upon all four client objectives.
Serving vs. displacing: AI as an enabler, not a replacement
One proposed use for large language models in the claims sector has been to automate action plans. It’s the adjuster's role to develop action plans that articulate their strategy for progressing claims. These plans are crucial for keeping clients and supervisors aligned with the adjuster’s approach throughout the claim lifecycle.
Providers envision applying AI to generate action plans with greater timeliness and consistency, even at scale. It’s easy, even tempting, to imagine how this could unleash adjusters to pursue other efforts, knowing AI is handling plan production.
However, would automating the action plan development process undermine a core client expectation: that adjusters take ownership of their files and cases? A well-written action plan is more than a document; it is evidence of the adjuster’s role and ownership. If AI were to generate these plans, would the plans be as insightful and would they remove adjuster accountability?
That’s where the balanced approach comes in. The automation and streamlined efficiency AI can deliver is revolutionizing the third-party claims administration sector. With people guiding the process, this oversight or supervision borne of the human touch is ensuring that injured individuals receive the thoughtful care and attention they deserve and clients, regulators and/or carriers realize quality standards. Additionally, TPA adjusters and nurses also enjoy a heightened experience.
This can help deliver optimized loss cost or outcomes and disability duration, heightened efficiency and an unmatched experience for client employees and risk management teams.
Our goal with AI is to ensure that high-tech solutions support industry-leading analytics while maintaining the high-touch, personalized and compassionate approach that customers and clients expect from our workers’ compensation claims process.
AI should not replace human expertise - it should amplify it. By striking the right high-tech, high-touch balance, we can harness AI’s efficiency while preserving the empathy and judgment that define high-quality claims handling.
About Broadspire
Crawford TPA: Broadspire® offers the most comprehensive integrated platform of claim, technology and medical management services in the industry customizable for any new or existing need. Backed by Crawford & Company’s more than 80 years of global experience in virtually every aspect of claims handling, Broadspire brings a superior ability to help resolve the unique and complex risks you face. Whatever claims management needs you have, we likely already provide that service or have the capabilities to create a tailored solution for you. Learn more at www.choosebroadspire.com
