How many claims justify using a nurse-triage program? This is a good question that seems simple but actually can be answered in many ways.
How Much You Spend on Claims Matters More Than How Many There Are
Here is a rule of thumb based on our experience over many years: most insureds who have 100 or more claims per year find triage to be justifiable by any measure, regardless of their industry or state. The savings from avoiding unnecessary claims and from improving in-network utilization far outweigh the cost of the triage call.
Many organizations with fewer than 100 claims also find triage to be financially justifiable. Here’s an example. If an insured has 24 claims a year averaging $2,000 each, it would spend $48,000. Even a mediocre triage service could help avoid 25% of claims, saving $12,000. (A top triage service could save almost twice as much!) The 24 triage calls would cost less than $2,400, yielding a net savings after triage fees of $9,600. In actuality, many claims cost much more than $2,000 each, meaning the triage service would save even more than $9,600, and additional savings in claims administration fees and productivity are also often realized.
The determining factor in cost justification is usually what an insured spends on claims, rather than its number of claims. High claims costs justify triage faster.
– Those that are self-insured realize the savings from triage immediately. Even on referrals that become claims, good triage providers improve in-network utilization, generating savings on medical fees. Top-tier triage providers also direct referrals to the right level of care (e.g. an occupational health clinic vs. an emergency room), generating additional savings.
– Employers in fully insured programs may think that they cannot benefit from triage because they incur the cost but the savings accrue to their carrier. In fact, employers save in several ways, though it takes time. Here is one example: Employers improve their experience modifier, which significantly lowers their premium cost in the future.
– Some insureds in time-sensitive industries with specialty jobs calculate that triage’s ability to help keep workers on the job is worth more than the claims savings.
– One of the most important considerations is the medical outcome – call it the “human factor.” The best triage service is focused on getting the right care for the injured employee. Sometimes, that means early identification of a serious condition or an unrecognized risk, and making a referral that creates a claim because it’s the right thing to do for the injured employee.
Bottom line: Insureds can justify triage in a variety of ways, not just by cost or claims count. The quality and consistency of the triage provider is a key factor, too – poor triage risks poor clinical outcomes, disgruntled employees and extra costs.