Success Stories
Integrated Claims Management System (ICMS), State Board of Workers’ Compensation (SBWC), State of Georgia
HCL designed and developed an Integrated Claims Management System (ICMS) to discharge the statutory responsibilities of the State Board of Workers' Compensation (SBWC) for the State of Georgia. The newly developed system supports a gamut of workers' compensation claims related activities and is responsive to every itemized and implicit requirement for the prompt, accurate, and complete processing of all matters pertaining to workers' compensation functions.
WHAT YOU NEED TO KNOW
The SBWC mission is to provide superior access to the Georgia Workers' Compensation program for injured workers and employers in a manner that is sensitive, responsive, and effective and to insure efficient processing and swift resolution of claims, while encouraging workplace safety and return to work and protecting the employer from tort liability. Workers' compensation is a statutory approach, which has been adopted by each of the states to provide specific quick and substantial relief to workers who have sustained an accidental injury or occupational disease during the course of their labor.
CASE STUDY
Georgia Legislature enacted the Workers' Compensation Law in 1920. The law created an organization called the Industrial Commission, the forerunner of today's State Board of Workers' Compensation, to encourage safety and assure benefits for injured employees. An employee injured on the job, covered by the law, is eligible for replacement of a portion of lost wages, medical payments, vocational rehabilitation services, and other benefits.
The State Board of Workers' Compensation serves over 187,000 employers and 3,380,724 workers. The Board is funded by assessments from insurance companies and self-insured employers.
- Claims Processing
- Data Processing (data coding and entry)
- Quality Assurance
- Alternative Dispute Resolution (Mediations)
- Trial (Administrative Hearings)
- Appeals
- Settlements
- Rehabilitation
- Managed Care
- Licensure
- Enforcement
- Human Resources
- Fiscal
- Training
- Information Technology
Business Challenges
SBWC spent a large amount of time validating information due to improper completion of board forms, applications and plans. These processes are paper intensive, tedious, time consuming, require an extensive amount of storage space and are expensive to maintain. Paper consumption is high due to notifications to different parties, and duplications and loss of data occur during transportation of claim files.
Claims were filed by pro-se parties or attorney representatives and were received via US mail into the Claims Processing Unit. Claims Processing sent all new claims to Data Processing for entry into the GO System. The claims forms were returned to Claims Processing Unit for file creation, storage and maintenance.
Registration of Rehabilitation Suppliers and Managed Care Organizations was also a manual process with a tie into the mainframe based Georgia Online (GO) Network. This application assisted in the provision of care for injured workers.
Additionally, the GO Network contained minimal data regarding claims; in essence it held information regarding the claims files but did not provide enough information to conduct research on history, calendars, progress reports, etc.
Invoices and reports were generated annually, mailed out to insurers and self-insurers and payments were received for assessments. The assessment system was a standalone PC application that contained redundant insurer and self-insurer information that was shared between the licensure and fiscal units.
Objective
The SBWC aimed to provide the following:
- Superior access to the Georgia Workers' Compensation program services for injured workers and employers in a manner that is sensitive, responsive, and effective
- Efficient processing and swift resolution of claims while encouraging employees' return to work
- Encouragement for employers to enhance workplace safety
System Architecture and Process Flow
The diagram below depicts the system architecture:
The following diagram depicts the flow chart:
Approach
HCL developed a web-based Integrated Claim Management System for SBWC which automated all the associated processes with claims management, alternative dispute resolution, trial, appeals, settlements, rehabilitation, managed care, licensure and quality assurance.
The project plan prepared was based on iterative approach using HCL Standard Software practices (HSSP) and Rational Unified process methodology. HCL believed that using iterative development, software could be integrated early at each iteration instead of at the end of the project. Also frequent integration dramatically reduced risk by exposing it early in the project lifecycle. Each iteration allowed meaningful feedback from SBWC and other agency users to witness the execution of a given iteration.
HCL utilized FileNet's Panagon suite of software products (content management, workflow management), customizing them to the specific requirements of the SBWC. This powerful COTS software is an industry leader in reliability and functionality, and is a proven performer in the workers' compensation arena.
Following is the list of core functions that ICMS addresses:
- Claims Processing – This module provides SBWC with complete claims processing functionalities. It includes activities related to the initial submission of a workers' compensation claim or notice of injury – the key generator of future needs and requirements pertaining to a specific work-related injury or occupational disease – and to the initial administrative evaluation or assessment that claim receives from the state authority and other parties to the specific claim, to include the resolution of any initial disputes or objections to the claim.
- Trial Management – Trial management functionality provides an accurate, user-friendly mechanism that enables timely dispute resolution by the SBWC. The ICMS provides aggressive trial management, incorporating all document reception and processing; calendaring and scheduling; party notification; decision generation, review, and approval; and the incorporation of any business rules considered germane by the SBWC to the entire ambit of informal and formal disputes resolution, to include appeals.
- Settlements – A customized workflow pattern applied to processing of claim settlements including advance or lump-sum payments, ensures that applications for settlement, advance payment, or lump-sum payment of benefits are accurately received and processed.
- Managed Care & Catastrophic Disability – The ICMS is customized to dispatch surveys related to the managed care and catastrophic disability matters electronically and/or by hard-copy generation to case participants
- Licensing – This module consists of internal customized data tables for the licensing of self-insured employers, workers' compensation insurance carriers, and rehabilitation providers, with customized document templates, document types, and workflows associated with the particular registration and re-registration requirements.
- Quality Assurance – The workflow patterns associated with the submission and processing of the Employer's First Report of Injury (WC-1) is customized to ensure that the forms are submitted in compliance with SBWC rules and regulations and that correct payments are being made to injured workers in a timely manner.
- Contact Management – The ICMS supports contact management functionality. Internal users are granted system access and action authorization by the SBWC System Administrator through the entry of requisite information into system data tables applicable to the internal staff. Similarly, external users will gain access to system information through a registration process incorporated into the system.
The network diagram detailed below describes the network environment for the ICMS.
ICMS has separate environment for Production, Staging, Training and Testing to validate the new system, to conduct training and support SBWC staff activities after delivery of the entire system to SBWC. The Staging, training and test environment is similar to the production environment however each has its own physical environment. The solution runs on a Windows 2003 based environment.
The system consists of following servers:
- Workflow Server
- Database Server (Oracle)
- Content Server
- Fax cum Print Server
- Electronic Data Interchange (EDI) Server
- Backup Server
- Report server
- Remote Access Server
- Voice Portal Server
- Web Server
- SUN ONE Identity Server
Platform: ASP .Net, VB .Net, FileNet (Webservices, FileNet Content Services, FileNet eProcess, FileNet Capture)
Results
The successful completion of the project resulted in the following service benefits:
- Improved customer service to the public - Additional service channels, more timely responses and the assurance of accurate documents are benefits, which have direct impact on the customer.
- Increased accuracy – Decrease in number of errors, through stricter system controls and standards, has led to more accurate documents.
- Decreased turnaround time - The implementation of a new system resulted in streamlined processes and the elimination of many manual operations.
- New and enhanced services for the customers by the services such as Internet renewals.
- Reduction of backlog – Decrease in turnaround time, through the implementation of more efficient processes, and increase in the amount of work the division is capable of processing in the same period of time.
- Customers have convenient and timely access to needed information i.e. the ability to quickly locate and retrieve documents has shorten response times to customer inquiries.
- Elimination of a large amount of manual work - Automated systems has replaced, or helped to alleviate problems associated with, many manual processes.
- Better data from which to manage - The system is capable of generating ad-hoc reports providing readily available business data that is used to make management decisions.
| COTS | Commercially Off-the-Shelf |
| GO | Georgia Online |
| GTA | Georgia State Agencies |
| HCL | HCL (Mass.), Inc. |
| HSSP | HCL Standard Software Practices |
| ICMS | Integrated Claims Management Solution |
| SBWC | State Board of Workers' Compensation |
