Tuesday, April 30, 2013

SmartSimple Community Conference: Case Management Summary

The SmartSimple Community Conference blog series summarizes the presentations given during the April 17th event. Keep checking back for more summaries, plus downloadable links to presentations! 

SmartSimple Business Analyst Brian Lai and Project Manager Madhulika Sharma's presentation, Case Management, gave our Community Conference attendees a comprehensive overview of our IME360°, Insurer360° and CMS360° systems.

Insurer360° allows insurer access to the Ontario Referral Network, which consists of over 80 independent medical examiners, hospitals and treatment centers. 500,000+ cases are available from these third parties, including 3.5 million medical documents and 150,000+ HCAI submissions per year.

The insurance adjuster portal was discussed next. All claim information is available upfront in the adjuster’s workbench, including current claims, report tools, an issue tracker, new claim creation and more.

Beyond Insurer360°, Brian and Madhulika explored how SmartSimple's CMS360° can be used across several lines of business. They showcased SmartSimple's Employer and Employment Services functionality and discussed how SmartSimple allows you to quickly and easily manage (among many features) employee files, contacts, billing, and case activities. They also discussed how various plan items are tracked in the system.

The next topic involved how SmartSimple is used to manage Structured Settlement cases. This is done within CMS360°. Many variables are considered, including amount of lump sum payments, frequency, interest rates, and life expectancy of the plaintiff.

A crucial feature shared between these systems is the Data Exchange ability. Notes, files, contacts, referrals and case statuses can be exchanged seamlessly between insurance adjusters and independent medical practices. This ensures consistency and harmony with every party involved in the case.

SmartSimple CMS360° from SmartSimpleSoftware

To download, please visit our SlideShare page.

Do you have any questions about SmartSimple and our case management systems? Don’t hesitate to contact us at info@smartsimple.com or call our dedicated Support team at 1-866-239-0991 x 1.

Thursday, April 25, 2013

SmartSimple Community Conference: FBA Smart Reports Summary

The SmartSimple Community Conference blog series summarizes the presentations given during the April 17th event. Keep checking back for more summaries, plus downloadable links to presentations!

During our Community Conference session titled SmartSimple Technical Discussion, Eric Babin of Firth Babin & Associates (FBA) presented FBA Smart Reports.

An authorized development partner of SmartSimple, FBA specializes in system integration and SmartSimple implementations.

FBA offers a service called Smart Reports, which is a browser-based reporting platform. This is offered as a SaaS model, meaning implementation is quick. Since Smart Reports run on trusted SmartSimple infrastructure, your data is safe.

Smart Reports utilizes a user interface that's intuitive and allows for the quick creation of new reports. FBA discussed how this service was geared toward general (or non-technical) users, due to its interface eliminating unnecessary technical details from view.

It is geared toward general users, as the dashboard is clean, easy to understand, and eliminates technical details. The entire service has been designed with non-technical users in mind.

There are many useful features of Smart Reports, including:
  • Data replication
  • Ad-hoc reports
  • Scheduled reports
  • Row-level security
  • Mobile device support
Future updates will include dashboards, cross-tab reporting and OLAP live data pivoting.

The next topic of discussion was why SmartSimple users would find this service attractive. Not only is the implementation for Smart Reports quick and affordable, it's an easy and headache-free experience for the end-user.

To download, please visit our SlideShare page.

For more information about Firth Babin & Associates, please visit their website.

Want to know more about SmartSimple or our future conferences and events? Visit our main site or email info@smartsimple.com to get in touch with us.

Wednesday, April 24, 2013

SmartSimple Community Conference: Tools to Communicate Summary

The SmartSimple Community Conference blog series summarizes the presentations given during the April 17th event. Keep checking back for more summaries, plus downloadable links to presentations!

Senior Relationship Manager Brad Robertson took part in our Community Conference to present Tools to Communicate with Your Community. The purpose of this presentation was to offer our clients an overview of the communication tools within their SmartSimple system.

The tools discussed were as follows (click the links to view their respective Wiki pages):
All of these features are already available in your SmartSimple system. They serve to aide the internal communication processes of your business or organization.

To download, please visit our SlideShare page.

Do you have any questions about SmartSimple and the communication tools in your system? Don’t hesitate to contact us at info@smartsimple.com or call our dedicated Support team at 1-866-239-0991 x 1.

SmartSimple's Best Practices and Lessons Learnt on... the Grant Application Process

We know that every organization is unique.

Based on years of feedback, we have learned several valuable lessons on how to create and maintain grants and research management solutions that are truly authentic to the needs of our clients.

We're publishing a series of blog posts to share these best practices and give you a better understanding of how your SmartSimple system works. This week, we're taking a look at the grant application process.

SmartSimple's Best Practices and Lessons Learnt on... the Online Grant Application Process

1. Use of a strong applicant profile greatly simplifies the information-gathering needs around a specific grant application.
It also greatly reduces the need for duplicate data entry. For instance, allowing the applicant to store all of their contact and organization information in the system means that their eligibility can be determined right away. Going forward, the only information entered relates directly to the actual application.

The above image shows how an applicants profile information is automatically attached to a grant application.

2. Always keep the results of eligibility questionnaires for each applicant.
By keeping results, you can analyze all applicant responses and determine how well the program fits against the community. This way, you can ensure that the eligibility criteria do not cast to wide or narrow a net.

3.Seeing the applicant’s draft application allows you to mentor the application process. 
By allowing all stakeholders to access relevant parts of a application and specific stages, feedback can be given at any point and not only when the application is submitted.

The above image highlights notes functionality that is used to facilitate communication during the application process.

4. Use an incremental application.
The use of an incremental application (i.e. an expression of interest that expands to a full application if approved) reduces work for the applicant and foundation staff.

Want to learn more about our grants and research management systems, GMS360° and RMS360°? Email us at sales@smartsimple.com or call 1-866-239-0991.

Monday, April 22, 2013

SmartSimple Climbs the C.N. Tower

SmartSimple is excited to announce that we will be participating in the 23rd Annual CN Tower Climb! On April 25, 2013 our intrepid team will be climbing all 1776 steps from top to bottom in support of the World Wildlife Fund (WWF).

The WWF works toward protecting endangered species and preserving the environment for future generations.

Visit our two team pages to show your support and donate today:

Visit WWF to learn more about the CN Tower Challenge.

For more information on SmartSimple, check out our website. Stay updated on all our events by reading our online Event Calendar.

Thursday, April 18, 2013

SmartSimple Community Conference: A Summary Series

On April 17, SmartSimple hosted our very first Community Conference at Victoria College! It was a great success, with lots of fantastic conversations and feedback from clients, partners and SmartSimple friends alike.

In the coming week, we’ll post individual session summaries and recap all topics covered. The sessions were as follows:

  • Opening Address
  • Get the Most out of SmartSimple with the Support Team
  • Next Generation Interfaces
  • Case Management - Managing More Lines of Business with SmartSimple
  • SmartSimple Technical Discussion
  • FBA Presents Smart Reports
  • Guest Speaker - Willie Handler
  • Grants and Research Management Discussion

Additionally, all presentations will be made available via our SlideShare account for public viewing. Keep checking our blog for more updates!

Check below the cut for pictures of our event setup, sessions in progress, the SmartSimple staff and more.

Wednesday, April 17, 2013

Firth Babin & Associates to Present FBA Smart Reports at Community Conference

Development partner Firth Babin & Associates (FBA) will be contributing a presentation on their FBA Smart Reports solution during our  Community Conference on April 17.

FBA Smart Reports allow for the quick creation of new reports within your SmartSimple System and provide an interface that’s easy for the end-user to navigate.

Firth Babin & Associates will be presenting this feature-rich solution to all interested parties during the Technical Session (1:30 – 2:30 pm) of the Community Conference agenda.

Read more about FBA and our partnership with them on their website.

Questions? Find out more about our Community Conference by contacting us at info@smartsimple.com, calling us at 1-866-239-0991 or visiting our main site.

Friday, April 12, 2013

Fraud Tools for Claims Adjusters Part 2 by Willie Handler (Guest Post)

Fraud Tools for Claims Adjusters - Part 2

by Willie Handler, Willie Handler and Associates

The state of the Ontario auto insurance product prior to September, 2010 was frightening. Accident benefits costs increased by over 100% in just a 4-year period. These cost increases have translated into higher premiums for consumers.

Many of those involved in the Ontario market believe that fraudulent activity have been on the rise during this period. Much of the evidence is anecdotal but the rapid increase in claim costs could not be ignored.  The situation was particularly acute in the Greater Toronto Area.

Following the 2010 auto insurance reforms, the Ontario government continued to work on anti-fraud initiatives. One of the more significant initiatives was the establishment of the Automobile Insurance Anti-Fraud Task Force in July 2011. The Task Force’s final report and recommendations were submitted to the government in November 2012 and implementation on those recommendations has begun.

What is Fraud?

The Task Force identified three types of fraud currently operating in Ontario’s auto insurance system: organized, pre-meditated, and opportunistic fraud.  

Organized fraud is defined as an organized scheme designed to generate cash flow through either staged accidents or fabricated accidents. Individual claimants are not the organizers of these schemes that often involve white collar professionals. Organized schemes use different methods to defraud insurers including staging collisions with innocent drivers and stealing the identity of health care professionals or accident victims.

Pre-meditated fraud involves an individual who consistently charges insurers for goods and services not provided or provides and charges for goods and services that are not necessary. Those involved in this type of fraud often do not believe their behavior is fraudulent and characterize the label as a reaction to disputes with insurers over entitlement to benefits. Pre-meditated fraud is committed independently and not part of a larger organization.

Opportunistic fraud occurs when individual claimants inflate the value of their claim.  Unlike organized or pre-meditated fraud, the individual committing the fraud does not engage in fraudulent behavior on a consistent basis.

SABS Change Since the 2010 Reforms

Following the 2010 reforms, additional regulatory tools were incorporated into the Statutory Accident Benefits Schedule (SABS) to assist adjusters in controlling fraud.

Verifying Invoices

Insurers need to ask for information to verify that a covered expense was actually incurred before paying an invoice. It is reasonable for an insurer to inform a claimant or their practitioner that an invoice will not be paid until it can be verified that the expense was incurred.

The SABS was amended effective July 1, 2011 to include a provision (section 46.2 of the SABS) that provides insurers with the right to inspect and copy original claims forms and other documents giving rise to a claim. An insurer can also request a statutory declaration, which is a statement made under oath, regarding the circumstances that gave rise to an invoice. The SABS was further amended so that effective June 1, 2013, insurers have authority to require the claimant to also confirm the receipt of goods and services that have been billed.

Benefit Statements

Effective June 1, 2013 FSCO will be authorized to the amount of information that insurers must provide in bi-monthly benefit statements to claimants. The intent of the revised provision is to provide claimants with enough information to help them identify suspicious billings.

Superintendent Guidelines

Subsequent to the September 2010 reforms, the FSCO’s Superintendent has issued a number of new or revised guidelines to address certain billing practices of health care providers.

HCAI Guideline

As part of Ontario’s crackdown on auto insurance fraud, the Health Claims for Auto Insurance (HCAI) Guideline (No. 07/11) has been revised effective December 1, 2011 to provide direction on a number of billing practices.

The submission of incomplete invoices by health care providers in regards to extended health care benefits (EHCB) can create "double dipping" situations where the provider receives payment from both the EHCB carrier and the auto insurer. To address this issue, the revised Guideline stipulates what information is mandatory on the Automobile Insurance Standard Invoice (OCF-21).

The submission of duplicate invoices and invoices for unapproved goods and services is a tactic that is sometimes used to obtain unearned payments from insurers. To address this issue, the revised Guideline prohibits these practices. 

Repeated and/or deliberate submissions of duplicate invoices and invoices for unapproved goods and services may be considered a contravention of terms and conditions by HCAI. This results in suspension or revocation of the health care provider's access to HCAI.

Effective July 1, 2012, FSCO issued an amended OCF-21 form in which the “Plan Number” of the OCF-18 or OCF-23 (to which the OCF-21 refers) is now a mandatory field.  This is the unique number generated by the HCAI system when the OCF-18 or OCF-23 is submitted, and will enable insurers to properly reconcile invoices.

Cost of Goods Guideline

The Cost of Goods Guideline (No. 01/12) has been developed as a result of a recommendation by the Auto Insurance Anti-Fraud Task Force in its interim report and became effective on January 4, 2012.  A SABS amendment was subsequently made to support the Guideline.   

Under the Guideline, the retail price is the lowest price, including delivery charges (if delivery is required), duties and taxes, that would be payable by or on behalf of a claimant to acquire an item of goods from a source that is available to a member of the general public in Ontario.

Contact Willie Handler by email or visit his official blog.

Click here to register your spot for Handler's guest Community Conference session.

Wednesday, April 3, 2013

SmartSimple in New York City - Interview with Cameron McLean

To celebrate the opening of our New York City office, SmartSimple is publishing a series of interviews with our staff to find out more about this exciting new move (and new city)!

For our last installment of SmartSimple in New York City, we spoke to Cameron McLean, the newly appointed President of SmartSimple Ltd. and the head of our Manhattan office. Cameron discusses his new position, acclimating to New York, and SmartSimple's plans going forward.

Congratulations on your new title as President of SmartSimple Ltd. How have you been acclimating to your new role within SmartSimple?

I am really looking forward to the opportunity and challenges that lie ahead with the role. One of the key philosophies of SmartSimple as a company, which is reflected in the SmartSimple platform, is the desire to develop strong communities. A huge amount of the company's growth in the last 12 to 18 months has been in the U.S. market, so setting up the New York office is one of the key pillars in our plan and a great opportunity to strengthen and expand our own community. We are looking forward to hosting our first U.S. Community Conference later this year. Stay tuned for details!

Have you noticed any differences between how business is conducted in New York versus Toronto? What adjustments have you had to make?

The biggest adjustment I have had to make since relocating is not being in the Toronto office and not being able to walk up to someone's desk at any time. That said, I have found that alternative tools such as Skype and WebEx meetings are just as effective. They actually help add structure and promote efficiency in the use of everyone's time. Of course, this is just an extension of the protocols we put in place some years ago when we opened our office in Dublin.

I am having a tough time remembering to use U.S. spelling: favorite vs. favourite; check vs. cheque. Canadians have the luxury of being able to use either. Having lived in London for 6 years, U.K. spelling became fairly ingrained and I am realizing (realising) how difficult it is to change the habit. Having one dollar bills instead of Loonies also takes some getting used to. I have gone out a few times thinking I have enough cash for dinner, only to discover they are all $1 bills and I only have about $15 to my name!

What hopes or expectations do you have for SmartSimple in New York for 2013?

For the next couple of months, we will be getting settled into the office and establishing all the operational processes and such that are required to support the expansion of the business. Following that we will be bringing more staff on board to work in the New York office as well as serve clients throughout the U.S.

Lastly, have you discovered any cool hot spots around the city (e.g., cafes, restaurants, places for people-watching, etc.)?

The vast array of restaurants and bars in New York is mind boggling. I am always willing to try something new, so I expect it will be quite some time before I choose any favorites and visit the same place twice. Until then, I'm trying as many new places as I can.

As an avid cyclist, I have started exploring various neighborhoods by bike. Although the traffic in New York is hectic (to say the least) there is a very decent cycling infrastructure which it makes it a convenient way to see the city. Later in the year there is a 100 mile bike tour that winds through Manhattan, Brooklyn, Queens and the Bronx that I am really looking forward to. I have also started a weekend routine of jogging in Central Park, which I am sure will start to become enjoyable as soon as the weather improves.

Want to know more about SmartSimple and our New York City office? Visit our main site or email info@smartsimple.com to get in touch with us.

Thank you for reading our SmartSimple in New York City interview series!

Fraud Tools for Claims Adjusters - Part 1 by Willie Handler (Guest Post)

Willie Handler will be a guest speaker for our SmartSimple Community Conference on April 17th, where he will present a session on claims management. 

Handler is an Ontario automotive insurance expert and the operator of Willie Handler and Associates, a consulting practice.

Fraud Tools for Claims Adjusters – Part 1

by Willie Handler, Willie Handler and Associates

The state of the Ontario auto insurance product prior to September, 2010 was frightening. Accident benefits costs increased by over 100% in just a 4-year period (Exhibit 1).

During the same period, assessment costs had increased by 250%, housekeeping costs had increased by 195% and medical costs by 120% according to data published by the General Insurance Statistical Agency (GISA).  These cost increases have translated into higher premiums for consumers.

Many of those involved in the Ontario market believe that fraudulent activity has been on the rise during this period. Much of the evidence is anecdotal but the rapid increase in claim costs could not be ignored.  The situation was particularly acute in the Greater Toronto Area.

The good news is that a number of initiatives both past and present are providing adjusters with new tools to address those that abuse the system and control costs. 

These initiatives include reforms that were introduced by the government on September 1, 2010, recommendations made by the Automobile Insurance Anti-Fraud Task Force and a number of guidelines released by the Superintendent at the Financial Services Commission of Ontario (FSCO).

September 2010 Reforms

Changes implemented on September 1, 2010 flowed largely from the first statutory five-year review that was submitted by the Superintendent to the Minister of Finance in 2009. The growing abuse in the system was a factor in many of the reforms. 

These reforms appear to have removed considerable costs from the system and have had some impact on fraudulent behavior. These changes were as follows: 
  • A standard medical and rehabilitation benefits coverage of $50,000 (reduced from $100,000) and included assessment costs;
  • A standard attendant care benefit coverage of $36,000 (reduced from $72,000);
  • Caregiver, housekeeping and home maintenance expense coverage now optional;
  • Capped coverage for treating and assessing minor injuries at $3,500; and
  • Capped assessment costs at $2,000 per assessment whether initiated by an insurer or a treating practitioner.

New SABS Fraud Tools

There are some significant regulatory tools in the new Statutory Accident Benefits Schedule (SABS) introduced in September 2010 to assist adjusters in controlling all forms of fraud.  

Minor Injuries

The SABS expands on the previous definition of whiplash-associated disorders (WADs) by including sprains, strains, dislocations, lacerations, contusions, abrasions and any clinically associated sequelae (secondary consequences or results of an injury) in a new minor injury definition. Including associated sequelae in the definition is meant to cover common complaints associated with soft tissue injuries such as pain, headaches, dizziness, difficulty sleeping, anxiety, depression and fatigue.

The Minor Injury Guideline (MIG) and a $3,500 cap on treatment and assessment expenses apply if the claimant sustains an impairment that is predominantly a minor injury. Currently, there is no guidance provided from the Superintendent, arbitrators or the courts on how to determine the predominant impairment of a claimant who sustains multiple impairments. However, another impairment may not necessarily create entitlement to medical and rehabilitation expenses in excess of $3,500.

The MIG was not intended to cover complete tears of muscles or ligaments, fractures or serious psychological impairments. Still, a minor fractured nose or finger may require little treatment in comparison to a WAD injury. Therefore, it could be argued that the WAD injury is the predominant one. Adjusters should seek independent medical advice when a claimant appears to have multiple impairments or a more serious impairment that would exclude them from treatment under the MIG.

The MIG and $3,500 cap do not apply to a claimant if his or her practitioner provides compelling evidence that a pre-existing condition prevents the claimant from achieving maximal recovery under the cap. There is no guidance as yet as to what constitutes "compelling evidence" but these situations should be rare and an independent medical opinion would be appropriate.

Common diagnoses used by providers to escape the $3,500 cap are psychological impairment and WAD III. Depression and anxiety are common complaints following an auto accident and often resolve themselves over time. That is not the case with post-traumatic stress disorder. Again, an independent medical opinion would be appropriate in these situations.

Incurred Expense

Although "incurred expense" has been a term used in the SABS since 1990, it has never been defined. Over the years the interpretation of the term has undergone some change. It was originally intended to allow claimants to be reimbursed for actual out-of-pocket expenses, such as payments for physiotherapy or the purchase of a wheelchair. Arbitrators and the courts have expanded reimbursement to include situations where no actual out-of-pocket expense exists.

The September 2010 reforms introduced a definition for "incurred expense". The new definition indicates that for an expense to be considered incurred, the claimant has already paid the expense or is legally obligated to pay the expense. Additionally, the person who provided the goods or services either did so in the course of the employment or sustained an economic loss as a result of providing the goods or services to the claimant. 

The plaintiff bar has not fully accepted the intent of the new definition and has suggested that any economic loss (such as the cost of gas while driving to assist a family member) would open the door to claim the full benefit. A recent court decision, Henry v. Gore Mutual, has shed some light on the new definition.

Direct Payments

Section 48 of the SABS covers the method of payments for medical and rehabilitation goods and services.  The common practice is that health care providers are paid directly by insurers despite the fact that the default rule in the SABS is that payments are made to the claimant.

Claimants are more than happy to have payments go directly to their providers. Insurers have discretion when it comes to paying providers directly except when specifically directed in writing by the claimant.

Stay tuned for part 2 of Willie Handler's guest post: Fraud Tools for Claims Adjusters.

Contact Willie Handler by email or visit his official blog

To learn more about SmartSimple IME360 °for Medical Claims Management visit our website.

Click here to register your spot for Handler's guest Community Conference session.