Tropics can dramatically improve productivity for claims system users by integrating documents and forms, imaging, and an effective rules engine, which automates the work management (diary) functions.
This comprehensive, multi-jurisdictional Workers’ Compensation claims system works in harmony with other Tropics systems to achieve end-to-end automation throughout your organization. The system is comprised of fully integrated modules that can be configured to fit the needs and goals of any workers’ compensation processing organization.
This unique architecture has significantly increased efficiency and accuracy for every Tropics claims administration client. Extensive research and gathering of information from different jurisdictions, including notices of injury, regulations, forms, and other requirements, constitute the processing foundation of this system. The system’s innovative architecture ensures richness, scalability, an efficient user interface, and the flexibility to allow for future needs as companies grow.
The system accesses policy data for full verification of coverage, and feeds summary claims data back to the policy system. This technique provides the foundation for seamless, accurate processing of loss sensitive and deductible policies, as well as the capability to run accurate and detailed billing for deductibles, retrospectively rated plans, loss ratio dependent dividend plans, and policy and unit statistical reporting.
SUMMARY OF TROPICS® CLAIMS SYSTEM MODULES
First Report of Injury (FROI)
To accommodate different data requirements in different states, Tropics provides state-specific First Report of Injury screens to enhance workflow and productivity. Additionally, Tropics provides a web based FROI screen for the employers to report injuries via the Internet. Whether a state requires FROI/SROI forms or EDI, Tropics accommodates the reporting requirements.
When a notice is received online, designated personnel will be alerted immediately via e-mail to process the incoming notice. When using the Tropics Claims System in conjunction with the, the FROI module verifies coverage, payroll class codes, elections of non-coverage, and assignment of a claim to a specific insured location.
In addition to providing a pre-defined reserve management screen for setting and changing reserves, the system interfaces with Microsoft Excel to give clients the capability of designing fully customized reserve worksheets. The fully integrated reserve management system automates all reserve activities related to payments and recoveries. The system also tracks “Committed Reserves” to the future payments without adjusting the reserves. The claims processing screens provide clear visual representation of how much of the reserves are used, committed to future payment, and available.
For a full demonstration of Tropics® Claims System,
Claim View / Processing
This powerful, effective user interface creates a single access point to view and process all activities of a claim. Through a unified user access point, the user is able to view all of the necessary data on a claim and to initiate new activities. All information related to a claim, including the payments, reserves, recoveries, etc., are only one click away when a claim is opened.
Medical and other types of providers are fully profiled in the system to enable accurate provider selection, medical bill adjudication, and financial processing. Provider specialty, language, 1099 and W9 processing options, and EOB method are amongst many parameters which are stored for each provider.
Recognizing that payment processing and financial management is the cornerstone of a claim system, Tropics provide a precise and feature-rich system for this purpose. The Tropics Payment/Recovery Module offers payment replication, auto-pay, and planned adjustments for automatically splitting indemnity payments as needed.
To facilitate bill entry, Tropics has designed multiple entry screens: indemnity, pharmacy, legal, physician, hospital, and other. Each screen is designed for efficient data entry. The recovery entry screen captures the data related to nature, amount, and source of recovery with capability to add user comments. The system allows booking of “anticipated” recoveries.
As an optional feature, Tropics provides basic state fee schedule reduction and re-pricing. For full medical bill automation and utilization review, Tropics interfaces with several third party bill review packages.
Check Processing & Financial Transactions
The Claims System provides a comprehensive module for processing payments and generating checks to the receiving parties. In addition to processing the payments for creating checks, the system creates the exact underlying financial transactions to record payments/reversals by claim number, claimant, benefit type, provider, reserve adjustment, and other financial facts.
The System allows for multiple payments to be combined into one check for a provider. In addition, it supports multiple bank accounts, MICR check printing, and check export for centralizing an organization’s check processing. Positive Pay and Check Reconciliation are optional features of payment processing. Optionally, payments may be processed through electronics ACH file submission to the bank.
Tropics has taken the basic functionality of a typical notepad and expanded it to include many modern and productive features such as storing sent/received emails, sending emails directly, and attaching documents and work items (diaries) to the notes. Text editing features such as bolding, highlighting, spell checking, etc., have been built into the notepad.
From this central view, a user may review notes, access documents and perform related work directly. In addition to several system note types for automatic creation of notes and tasks that are completed throughout the Claims System, the system provides capability of user defined note types.
Email Notification System
The Email Notification System is and optional mass background emailing system that creates and send emails based on pre-defined email templates. Emails may be issued to external and internal recipients, based on defined rules, without user intervention.
This system is used in automating many of the required notifications such as “Bill is Ready to Pay” “Payment Reminder”, “Past Due Notice, “Self Audit Reminder”, “Termination Notification”, and many other types of notifications.
Document Management & Imaging
Our clients have achieved unprecedented level of productivity through the integrated document generation engine and the optional Tropics Imaging Module. Please see the Document Management & Imaging.
As an optional module, the Tropics Reinsurance System is a tightly integrated Claims Module that provides for the user definition of reinsurance arrangements and automated reinsurance processing including reporting and recoveries. The system is configured by defining reinsurance layers with parameters such as attachment point, aggregate limit, reinsurance reporting triggers, etc.; and then combining layers to create reinsurance plans. A reinsurance layer can be attached to a single reinsurer or a group with quota share.
Employing the features of work management and document management, the system tracks incidents for reinsurance processing and generates reinsurance reports, recovery statements, and notifications.
The Tropics optional Case Management module is provided for managing serious medical cases. A claim is referred to a case manager familiar with medical protocols and procedures (usually a nurse) to manage the case through a series of case management screens. The system provides one place for a well-rounded picture of the total treatment of the injured worker.
ISO Claim Search Online
The optional ISO Claims Search Module automates the process of submitting claim information to ISO’s national claim database via the internet using real-time Web Services and XML. This Claims Search functionality allows clients to quickly discern whether the claim could be fraudulent due to any other claims in ISO’s database that produce a match. A claim may be transmitted to ISO and within seconds a response with possible matches (claims history) is received back. The history is permanently stored and can be viewed at any time. The system can also receive automatic updates from ISO if any claims are received from other companies that match previously submitted claims.
Reports, Custom Reports, & Ad-hoc Information
The Tropics Claims System allows claims professionals to access a large amount of information on-line, reducing the need for printed reports. This feature enables users to react to customer inquiries more quickly and with greater accuracy. The ability of the claims staff to select, sort, and view information on-line lessens the burden on the in-house IT staff to produce and print reports. As an added feature, when a view is selected, sorted, and displayed on the screen, the grid can be exported to the desktop Microsoft Excel with a click of a button.
Additionally, Tropics provides a number of financial, management, and exception reports which can be printed or viewed online. As an option, Tropics adds a significant level of capabilities in reporting, analysis and trending, as well as access to ad-hoc information through OLAP cubes, delivered with the Tropics Business Intelligence Module.