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Artificial and Emotional Intelligence: Finding the Perfect Balance for Optimal Claims Outcomes

By Gary Anderberg PhD, SVP-Claims Analytics, Gallagher Bassett Services [NYSE:AJG] And Gia Sawko, VP-Professional Development, Claims Operations, Gallagher Bassett Services [NYSE:AJG]

Gary Anderberg PhD, SVP-Claims Analytics, Gallagher Bassett Services [NYSE:AJG]

In this day and age, technology plays an essential role in our everyday lives. It wakes us up in the morning. It gets us from point A to point B. It can even order our coffee for us when we’re running late. Without technology, we might have accidentally slept in; taken a wrong turn or fallen asleep during our 9AM meeting. We can perform better when we utilize the technology available to us.

In the claims management business, it’s no secret that resolution managers, commonly referred to as claims adjusters, are key decision makers throughout the claims process. When resolution managers are approached with an unusual claim, unlike any they’ve worked with before, they look for guidance to expand their knowledge so they can make the best possible decisions.

Think about it—how many times have you pulled over in a place you’ve never been before to check your directions and ensure that you’re going the right way before you start driving again?

Resolution managers do this daily. They “pull over” and take advantage of Artificial Intelligence (AI) systems, such as Decision Support Solutions, that are available to assist them.

Looking Ahead

It’s fascinating to consider the possibilities that such advanced forms of AI offer for the future of claims operations. Will we soon be able to find ways to apply diagnostic AI to detect errors before a course of treatment and claim goes down the wrong path? Research has shown that initial diagnoses by front-line medical providers dealing with on-the-job injuries are often partly, or entirely, in error. With continued development of AI capabilities, AI systems have the power to revolutionize the way that claims are managed.

"AI systems certainly help resolution managers gain sufficient knowledge; however, it is EI skills that allow resolution managers to connect with claimants on a deeper and more meaningful level"

Computers Never Have a Bad Hair Day

One example of an AI Decision Support Solution that is currently used in claims processing is a multipurpose system named Waypoint. Waypoint sorts data by scanning the words used throughout various reports written by doctors, registered nurses, previous resolution managers and any additional parties involved during the life of a claim. It also categorizes claims based on keywords associated with specific injuries, as well as analyzes patterns in all aspects of claim data captured in the adjusting process. This brings previous, comparable claims and related material to the resolution managers’ attention and provides them with insight on how the claim could be handled.

Influencing Outcomes

With the insight gained from resources like Waypoint, resolution managers can confidently move forward in the claims process and focus on what they do best—helping people.

Gia Sawko, VP-Professional Development, Claims Operations, Gallagher Bassett Services [NYSE:AJG]

While AI systems make it easy to access massive amounts of information at any given moment, they are limited to categorical measures. What an AI system is not capable of is human interaction. It cannot listen, understand and sympathize with a claimant. The pain in a person’s voice cannot be interpreted by an AI system. Emotional Intelligence (EI) is defined as “the capacity to be aware of, control, and express one’s emotions, and to handle interpersonal relationships judiciously and empathetically.”

Most people are relationship-driven—they want to know they are cared for. Emotionally intelligent resolution managers can make an injured worker feel comfortable by making a personal connection at first contact. A trusting relationship is established when resolution managers express that they are there to guide an injured worker through the claims process, and answer the worker’s questions. Excellent resolution managers demonstrate care and compassion, and consistently create rapport with all parties involved.

Opening Your Ears

It’s imperative for a resolution manager to be engaged and an active listener during every conversation with a claimant. Conversations tell more about a person than just the words that they say.

Resolution managers are able to hear what’s important to the claimant when they listen intently. If they truly pay attention, they can hear not only what is being said, but how it is being said. Claimants may emphasize certain words, change their tones of voice or mention certain topics multiple times without realizing they are doing it. These are all behaviors that a good resolution manager will recognize and know to ask further questions about. Asking relevant questions gives the resolution manager a better understanding of how he or she will be able to help.

This is what sets “Resolution Managers” apart from “Claims Adjusters.” There is nothing comforting about what claims adjusters do. Their work is viewed as transactional and process-driven. Resolution managers, on the other hand, put forth a conscious effort to make their claimants feel cared about. They never want a claimant to feel like just another claim number. They work tirelessly to find solutions and resolve a claim in a way that satisfies all parties involved in the process.

Resolution managers want to satisfy their client, but they also want to see their claimant’s quality of life improve. One small action can go a long way in the business of putting people’s lives back together.

Finding the Balance

Resolution managers ultimately determine what the outcome of each individual claim will be. They have this responsibility because they’ve mastered the balance of using AI resources and their personal EI skills to make critical decisions. AI systems certainly help resolution managers gain sufficient knowledge; however, it is EI skills that allow resolution managers to connect with claimants on a deeper and more meaningful level. Finding a harmonious balance between AI and EI ensures more positive results and optimal outcomes for claimants and clients alike.