Achieving Balance: Technology Advancements v. Human Care (Part 2)

Stephen Elliott, MBA, JD, CISSP, CSM
Senior Vice President, IT Innovation and Decision Optimization, Sedgwick
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Click HERE to Read Part 1

Speed and Automation

Technology trends in the claims industry focus heavily on auto-adjudication and claim durations.  In a perfect world with tomorrow’s technology, almost all claims could be adjudicated without human review.  This would allow them to be completed instantly after the appropriate data is provided by the claimant, medical providers, or the employer.  With the increase in AI driven predictive models, many claims might even be adjudicated and paid before all data is provided based on what is most likely or expected.

But this comes with a cost.  The pursuit of speed reduces human touch.  While some claimants may be pleased with quicker turnarounds, the risk of leaving them feeling “cold” increases.  While monetary considerations are important, many injured parties want to believe that a claims examiner cares about them.  If the claimant doesn’t feel that empathy, litigation can ensue and costs can increase, irrespective of the initial injury or payment.

Of utmost importance is the ability to walk the line between speed and empathy, adjusting based upon the particulars of the case and the signals provided by the claimant.  Claims that are auto-adjudicated need to move to slower, more human-based processes where needed….and vice versa.  Successfully managing a claim depends upon on the accurate identification and satisfaction of the claimants’ wants and needs and providing them the level of automation and humanity they desire.

It might also be best to leave the final decisions with humans.  New technology can analyze, predict and recommend...but leave the ultimate decisions in the hands of human beings..  No matter how good the technology becomes, it will never be perfect.  Thousands of years of human experience has led us to understand that people make mistakes.  Marketing, movies, and the speed of technology has also led us to incorrectly expect that machines should not.

Logic:  Identify the damages, provide the treatment plan and pay the costs….quickly.

Empathy:  Ensure the claimant understands they are not just a number too.  Handle the claim at the speed and with the automation appropriate for the case.  Be prepared to adapt.


All this implies that the key to successful claims management is identifying who should be involved and when.  Automation needs to be balanced with human involvement.  Computers can be effective at triaging claim complexity such as chance of escalation, fraud or other high risk elements, and notifying additional human resources such as supervisors or nurses to better monitor the specific claim situation.

Organizations will be well served by focusing on technology that collects more and better information early in a claim to facilitate this triage.  Collecting more data earlier increases confidence in predictions and triage. But, challenges can arise in data collection, claimant availability and overall satisfaction in the process.  As long as a human is involved in providing data, challenges will exist in obtaining it early and accurately.

Optimal results will be obtained by providing quick, low touch care when wanted….and more sympathetic human based care when THAT is wanted.  Being able to adapt quickly to claimant needs will help to distinguish the “winners” from the “losers” in this space.

Logic:  Collect accurate data quickly and determine how best to assist the injured worker.

Empathy:  Involve the appropriate human resources when the situation requires it…and preferably before the injured worker becomes frustrated.

Final Outcomes

Data collection should not solely be left to machines.  While we might believe that technology makes collecting data easier, it has also been shown that collecting additional information is much easier when the requestors are demonstrably empathic.  AI can be better at reading medical images and identifying illnesses but understanding what that means for the patient and how care might be optimized for that individual is still firmly set in the realm of human intelligence.

Treatment plans also play a major role in outcomes.  If plans are not followed, prescriptions not taken and therapy not continued, injuries can linger and overall outcomes worsen.  Empathic physicians and caregivers have a significant impact on patient adherence to treatment and, in the worst cases, bad news is best delivered with caring.

So long as injured workers are human beings, then human caregivers and examiners will be needed to optimize outcomes after injuries.  Success or failure will be driven by how organizations can personalize care based upon the individuals’ needs.  Technology will bring speed and accuracy, but empathy will remain in the realm of human beings for all of the foreseeable future.

As Bill Gates once stated:  “The advance of technology is based on making it fit in so that you don't really even notice it, so it's part of everyday life.”  That doesn’t sound extreme….that sounds balanced.

*The views and opinions expressed in the Public Risk Management Association (PRIMA) blogs are those of each respective author. The views and opinions do not necessarily reflect the official policy or position of PRIMA.*

    By: Stephen Elliott, MBA, JD, CISSP, CSM
    Senior Vice President, IT Innovation and Decision Optimization, Sedgwick

    Stephen is the SVP of IT innovations at Sedgwick in Memphis, TN. In this role, he is driving IT to leverage new technologies and stay ahead of the competition. Previously, Steve has built and led a multi-disciplinary team (140+ team members) supporting the application design, development and maintenance for the disability and leave line of business at Sedgwick. Prior to joining Sedgwick in 2005, Steve worked at Deloitte Consulting and was a partner in several consulting firms, specializing in technology financial management.

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