Tropics® Claims Administration System (Claims System)

The Tropics claims system is a comprehensive, multi-jurisdictional Workers' Compensation claim processing and claim financial system. The system is comprised of fully integrated modules that can be configured to fit the needs and goals of any workers' compensation processing organization. The technologically advanced system is built inside an automation framework consisting of integrated workflow, document/forms, e-mail/alerts, and configuration/security tools.

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 Claims System is fully integrated with the Tropics^® Policy System to provide a full-featured workers' compensation system. 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

WORK MANAGEMENT/DIARY

Work Management, as a user-controlled, rule-based automation engine, is one of the most important and fundamental components of the claims system. Within this module, clients define claims teams and workflow logic to automate system activities based on their business rules.

A Work Management Team is created by defining the team purpose, creating roles, and assigning users to the roles. Roles are defined by the client to match their organizational structure and offer fl exible assignment of users to those roles on teams. Tropics is designed to use a "best match" methodology to assign claims to teams by precisely matching the characteristics of a claim to the characteristics of each team. Clients create teams and assign attributes to the teams as necessary.

A Work Management Tree is a user-defined road map consisting of a series of logically organized and cascaded actions and decisions. Through the work management tree, every action on a claim can act as a trigger to invoke other action(s) and decision(s) followed by more decisions and actions. Automatic diary is one of the basic features of this robust system. Actions and decisions can also lead to automatic creation of forms, document, and e-mails.

DOCUMENT MANAGEMENT

Tropics® Claims System's Document Management Module provides a robust user interface and tools for creating, storing, and managing all forms and documents generated by the system. Forms and letters, regardless of method of creation, whether by a process or by a user, are stored within this system. This system has included and integrated features of MS Word, Excel, and Adobe Acrobat. The system administrator can create MS Word and Adobe Acrobat form templates that can be added to the system for access by the system users. Upon creation of such templates and forms, the data from the current claim, payment, etc. is filled automatically into the forms and templates based on an innovative method created by Tropics. Claims jurisdictional forms are created in PDF and configured within this system for automatic creation of state mandated forms.

FIRST REPORT OF INJURY (FROI)

Due to different data requirements in different states, Tropics provides state-specific First Report of Injury screens to enhance workflow and productivity. Additionally, Tropics provides a webbased FROI screen for the employers to report injuries via the Internet.

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 Tropics® Policy System, the FROI module verifies coverage, payroll class codes, elections of non-coverage, and assignment of a claim to a specific insured location.

CLAIM VIEW/PROCESSING

This powerful, effective user interface creates a single access point to view and process all activities of a claim. This tabular screen enables the user to view all of the necessary data on a claim and to initiate new activities. The tabs contain general, injury/illness, claimant, employer/job, legal/other, carrier/TPA, and jurisdiction information. Claims information such as payments, reserves, financial summaries, work items/diaries, notes, documents, and imaged documents through ImageRight* are only one click away from this central access point.

* ImageRight, a third party document imaging solutions company, is a trademark of Advanced Solutions, Inc.

As a Platinum Business Alliance member of ImageRight, Tropics provides a tight integration with ImageRight products.

RESERVE MANAGEMENT

In addition to providing a pre-defined reserve management screen for setting and changing reserves, the system interfaces with Microsoft Excel to give a client the capability of designing a fully customized reserve worksheet. The fully integrated reserve management system automates all reserve activities related to payments and recoveries. While the system facilitates reserving by the well-known types of medical, indemnity, expense, legal, and other, it goes further and allows breakdown of each of the types to user-defined pay codes. For instance, medical reserves may be further broken down to physician, hospital, pharmacy, etc. 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.

PAYMENT/RECOVERY PROCESSING

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, related parties, associated parties, and planned adjustments. 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.

Bills can be entered and processed in the system with detailed line items including CPT4/HCPC, diagnosis, National Drug, Procedure, and American Bar Association. For each line item, one or more adjustments can be made based on pre-defined adjustment or Explanation of Bill Review Codes.

As an optional feature, Tropics provides basic state fee schedule reduction. For full bill automation and utilization review, Tropics interfaces with several third party bill review packages. Tropics® Claims System also provides the necessary tools for receiving, categorizing (disability, trust, reinsurance, subrogation, etc.), booking, and making adjustments for recoveries.

The recovery entry screen captures the data related to nature, amount, and source of recovery with capability to add user comments. In addition to the actual process that automatically updates the reserves and creates the adjusting fi nancial transactions, the system allows booking of "anticipated" recoveries.

CHECK PROCESSING AND 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 fi nancial transactions to record payments/reversals by claim number, claimant, benefit type, provider, reserve adjustment, and other financial facts.

Many arduous tasks related to payment and check processing are automated, thereby allowing the claims staff to concentrate on more important tasks. The Tropics® Claims System also 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 Processing is an optional feature of payment processing. It facilitates creating an electronic file of issued checks for the bank to prevent fraud and ensure accuracy of cleared checks.

Check Reconciliation is another optional feature. It allows receiving an electronic transmission of cleared checks from the bank and reconciliation of the cleared checks to the Tropics check register.

REINSURANCE

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.

CASE MANAGEMENT

Tropics® Case Management (also referred to as Patient Advocacy), is another optional module 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.

Claimant characteristics, past and current prescriptions, as well as occupational and educational history can be tracked. The system provides for unlimited entry of medical, legal, and employer contacts, as well as prescriptions, appointments, medical equipment, and a comprehensive treatment plan. To complete the module, the outcome of treatment (including areas to track ongoing disability and work status) is provided.

ISO CLAIM SEARCH (ONLINE)

The Tropics® ISO Claims Search Module automates the process of submitting claim information to ISO's national claim database via the internet using Web Services and XML. This Claim 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. After entering a claim, with a click of a button, the claim is transmitted to ISO and within seconds, a response with possible matches (claim history) is received back. The history is permanently stored against the claim 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.

INQUIRY AND REPORTS

The Tropics® Claims System lets claims professionals access a large amount of information on-line, reducing the need for printed reports. This allows users to react to customer inquiries quicker 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 IS staff to produce and print reports. As an added feature, when a view is selected, sorted, and displayed on the screen, it can be sent to the printer with the selection of a command button.

Tropics provides a built-in Crystal Reports engine for viewing and printing business reports. Utilizing the Tropics® database and Crystal Reports the reporting ability is virtually unlimited. Reports can be designed using any of the data elements available in the Tropics® database, combined with user entered variables, and added to the Tropics® Reports Menu. The reports can be printed, e-mailed, or faxed. In addition, many SQL reporting tools can be used to create ad-hoc queries against the Tropics® database.

Web inquiry search of payments can be sorted and selected by numerous categories or combinations of categories including: claim number, payee, adjuster, invoice number, payment level, procedure code, legal code, data range, payment type, etc.

OTHER FEATURES

Notepad - The system includes a full-feature notepad to allow creation, categorization, organization, and review of notes by types e.g. Adjuster Notes, Legal Notes, Medical Notes, Reserve Information, Status Report, etc. It compliments the Tropics® Workfl ow Management, Document Management, and other Claims System Modules by linking the activities directly into the Notepad. The system automatically creates notepad entries as tasks that are completed throughout the Claims System, therefore, providing a full history of claim activities.

Context-Sensitive Help - The description of any data item on the screen may be displayed by pressing a function key. Furthermore, if the field carries a code value with multiple descriptions, the system will display all the valid codes and descriptions.

On-line User Manual - The user manual can be accessed from any point in the application through a specified function key. The access method will locate and display the appropriate chapter for the screen from which the manual is invoked. The manual is in the standard, and popular, Adobe Acrobat PDF format.

For a full demonstration of Tropics® Claims System, please fill out this form.