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Underwriting and Claims

How Much Is Enough?

long-information

Have you heard the terms "infobesity" or "infoxication"? Neither had I, until I started researching the term,"information overload". Just like Monty Python's infamous Mr. Creosote, we're stuffed with so much information that even just one more "wafer-thin" piece of data might cause us to explode – and wouldn't that make for an interesting disability claim! It's time to think seriously about pushing away from the buffet!

Bertram Gross in his book, The Managing of Organizations, states: Information overload occurs when the amount of input to a system exceeds its processing capacity. Decision makers have fairly limited cognitive processing capacity. Consequently, when information overload occurs, it is likely that a reduction in decision quality will occur.

This book was written in 1964.

Think about where we are today with truly unlimited access to any information we (and our claimants, policyholders, physicians) could possibly want or need. There are hundreds of thousands of medical websites, tweeters, medical bloggers, disability bloggers, mommy bloggers, travel bloggers, food bloggers, (not to mention Facebook!), and on and on and on. Eeeeek!! It's overwhelming!

As an RGA Disability Claims Consultant, I have the opportunity to assess our customers' claims, and it is rare when we do not see standard forms in claim files stating something like, "Please forward all medical records on Mr. Jones, from 1/1/2012 through the present." This is truly one of my pet peeves – and talk about information overload! Do you really need to know about Jones' last four sinus infections or his broken big toe? Do you really need all his lab results? And when it comes to hospital records, do you really need more than the discharge summary?

What does this all cost – in time and money?

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Decisions, decisions

When it comes to making a claim decision, what would disability claim analysts/case managers say is the #1 most important information they must have? Chances are very good the answer is "medical records." The question is, "Really, how much is enough?" Has our ability to insist on receipt of medical records - sometimes ALL medical records, whether or not they relate to or impact the disability claim - become a means to an end?

The key is to obtain only the information you need to make a decision, whether it's an initial approval or ongoing proof of disability. The recommendations offered here may require a little more "up front" effort, but will save hours and dollars as claims are approved and managed over time.

Recommendations

A claim examiner's time is best spent centering her efforts on early, substantive phone calls, asking for very specific information relevant to the individual claim for benefits, and focusing on functional abilities. Obviously, although diagnosis does not equal disability, there are some diagnoses that warrant an altered approach.

Call the claimant: Research shows that the language used and questions asked in the initial phone contact can impact thinking and self-efficacy. Questions such as: What are you able to do at home? What parts of your job do you think you could do right now? Do you have any ideas for job modifications that might be helpful when you're able to return to work?

While it's important to understand the medical condition from the claimant's perspective, the claim examiner likely has the Attending Physicians Statement in hand, so a quick review of that information to obtain confirmation and clarification is all that is necessary. In doing so you may also learn about other conditions that could be contributing to the claimant's disability, other treatment providers, and elicit the claimant's assistance in gathering necessary information from the medical providers.

Call the policyholder: Again, the language used and questions asked in this important conversation affect the outcome of the claim. Explain the purpose of your call is to understand job demands, possible return to work options, and to clarify any workplace concerns. The opportunity to educate and collaborate with the employer with the sole purpose of facilitating a gradual return to work is significant.

Write letters: Based on the information gathered from the claimant, correspond with the physician, hospital, and ancillary providers such as physical therapists. Asking detailed, focused questions relative to the particular claimant and his/her condition. If this is a chronic condition, you may want to request documentation from the initial date of reported symptoms. In many cases, however, months and months of medical records just aren't necessary. Again – direct your questions toward function: Your patient reported having this condition for several months and was able to continue his normal routine, including working – what changed? What kinds of treatment are available to assist your patient in increasing his functional abilities? What factors might be impacting his ability to return to a more normal level of activity? In other words, no more "blanket" requests for all medical information. Ask only for what you really need. Your internal physician consultant can also be a useful resource in identifying appropriate questions to ask.

Turnaround time

How much time is wasted in the pursuit of possibly unnecessary data? In this culture of information overload, we also have the pressure of immediacy – people want an answer now, not in 15 minutes or 3 weeks. It's a conundrum…all of this incredible amount of information to sort through (think information overload) yet we still have the expectation of an instant solution to what are often very complicated scenarios. Keep in mind that no one understands "turnaround time" when they're waiting for a benefit decision and a check in the mail.

It's all about customer service

Using the phone (yes, actually having a real conversation!), writing letters, pursuing only what you must have in order to make "full and fair" claim decisions absolutely saves time in the long-term. You're obtaining only the information you want, you're explaining the reason why you need it, you're facilitating better and positive claim outcomes, reducing claim durations - and you're providing excellent customer service.

The disability insurance industry continues to provide the service its customers expect. Even within the craziness of an Internet world, human beings still respond to personal, focused information requirements when the questions are reasonable and the need is understood.

And finally, consider again Mr. Gross's words: Decision makers have fairly limited cognitive processing capacity. Consequently, when information overload occurs, it is likely that a reduction in decision quality will occur. If that doesn't help, remember Mr. Creosote!


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The Author

  • Sue Favilla
    Senior Disability Claims Consultant (ret.)
    U.S. Group Reinsurance

Summary

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When it comes to making a claim decision, what would disability claim analysts/case managers say is the #1 most important information they must have? Chances are very good the answer is "medical records." The question is, "Really, how much is enough?" This article explores. 
  • Attending Physician Statement
  • APS
  • big data
  • claims investigation
  • large claims
  • claims