ACM’s claims platform sets them apart from other TPAs
One of the key differentiators of ACM over other third-party claims administrators is the way we utilize our cutting-edge technology claims platform, Systema SIMS Claims™.
ACM’s claims platform is a pure browser-based system built by experienced enterprise system architects, with direct input from a knowledgeable group of seasoned insurance professionals. Many of these insurance experts continue to work for ACM. A paperless role-based system, our system can handle just about any requirements needed to capture data at its most granular level.
The claims platform is completely integrated with our nursing, bill review, investigative and recovery teams. This means all the appropriate data is shared and can be leveraged to obtain the most accurate outcomes.
We sat down with ACM’s Robert Simpson, senior VP of property & casualty and Cheryl Gulasa, VP of managed care, to discuss this robust system and how it’s used by ACM.
“Our claims platform is an architecturally superior system with robust performance and extensive features designed to maximize efficiencies and profitability,” explained Simpson.
As a pure web-based system, ACM’s claims platform is supported by a relational database and an intuitive user interface. It provides advanced functionality needed to support a complex and multi-jurisdictional claims operation:
Each module seamlessly interacts with Microsoft Office/ Adobe products, allowing information and reports to be exported to Excel, XML, Word, PDF and Outlook with a simple click of a button.
- Ad hoc reporting is available via SQL Server Reporting Services.
- Clients access the system via Citrix Portal.
- Role-based security manages access to areas and functions of the application, plus drives the user workflow and address client specific requests.
Claims Reporting
“Extremely important business tools, our reports ensure that you are getting real value from your data,” said Simpson. “Because the reports are derived from client requests, each answers real business questions that users have, from claim statistics to adjuster performance. Most are generated from the platform’s data warehouse, which ensures fast performance and avoids impacts to the transactional database.”
All reports can be exported automatically to many formats including PDF, Excel, Word, XML, CSV and TIFF, he explained. The platform provides users the ability to automatically receive reports via email through subscriptions, to access reports from the report manager module on an ad-hoc basis, or to analyze reports within the context of their business processes via controls embedded directly in the application.
“This sophisticated, role-based technology assists in capturing data for performance metrics off any field in in the claims system. Then it can create any customized reports, customized automation and customized alerts/triggers that your business needs,” Gulasa explained. “It’s designed to notify different parties at various intervals regarding transactions that occur in the system. As our fail-safe to circumvent human error, we use a combination of alerts in the form of an email, a diary notification, or daily, weekly and monthly reports delivered automatically to the adjuster, manager and executive management.”
The claims platform is “real-time,” she added. Once the adjuster enters the document into the system, it is available for viewing by all parties. All team notes are categorized by type and contain a subject. Systems can show all or exclude certain notes by type. Clients can view all notes in the system except for HIV/John Doe notes.
“Minus that exception, you will see what we see and have access to all data real time, including specific reports created for your account with the ability to run them at any time,” she said.
Data Conversion
“The most critical part of any system conversion is the data conversion,” said Simpson. “Ensuring accuracy and thoroughness is crucial. Our data conversion team has extensive experience converting data from a variety of systems, making this process straightforward and reliable.
“By providing detailed documented mappings of the legacy system to SIMS and reviewing it with the client, we ensure that every piece of data has an approved destination. Once mapping is complete, scripts are created to provide an accurate and repeatable process,” he said.
The data conversion process starts with trial conversions of the client’s data into our system and continues with the validation, approval and final conversion. Proven comprehensive conversion reports are used for validation. In most cases, the final conversion process can be done over a weekend to prevent any downtime in the program’s operations.
Data sharing
All ACM team members plus ancillary teams such as medical management, investigation and recovery specialists work in the same claims platform. All documentation is shared to ensure seamless transfer of knowledge and data. All parties facilitating on the claim file are “on the same page,” having access to the same data, so that no time is lost. Parties can execute all tasks efficiently, effectively and in the least amount of time.
Housing all documentation in one place is a key advantage and differentiator for our customers. Our team members save considerable time by not having to log in and out of different systems to retrieve crucial information. It minimizes mistakes that can happen if key information is missing. It also streamlines action steps that should be performed in minimal time.
“For our customers, the key advantage is the ability to track data and metrics in one easy place, with access to literally any information they need,” said Gulasa. “Better yet are the checks and balances that exist to ensure actions on a claim file are performed on a timely basis.”
The role-based system can capture all client special handling requirements as well as statistics from a client level, all the way down to a location.
Simpson provided an example of a client with multiple locations and different team members who handle the different locations; plus, each location has a specific set of different instructions. The database is then noted with this handling requirement. This instruction is also imported automatically for any claim that is associated with that client/location, to ensure all handling requirements are addressed. Reports and alerts are created around those handling instructions through various levels of the system, to ensure our compliance with your requests and needs.
The claims platform also can capture data for performance metrics to measure claim intake results. Its three-point contact module captures all data elements for the claim intake. The module can measure various aspects of the intake process. All reports are customizable to the client’s specific needs.
In a future article, we’ll take a deeper dive into how ACM’s claims platform facilitates adjuster performance, automated processes, benefit calculations, system-generated checks and more, all with the goal of more efficient claims outcomes.