An Introduction To:
- The Structure of a Case
The definition of a case in W5 depends upon your perspective.
A case can be an engagement to conduct one or more reviews and/or examinations related to an insurance claim, a worker’s compensation claim, an employee benefits claim or a treatment plan. From this perspective, a case is essentially the medical evaluations component of a claim.
Insurance company claim for a claimant = your case
A case may also be an engagement to manage and apply or to determine the appropriate medical / disability benefits to the rehabilitation effort for an injured worker. From this perspective, a case is the medical rehabilitation component of an injury.
Claimant accident or injury = your case
Regardless of the perspective a case is the mechanism that W5 uses to encompass all of the services that you will provide for a claimant/injured party as may relate to a single accident or claim.
The important aspect of a W5 case is that it relates to a single “claim” and that it may contain one or more services.
A W5 service is essentially the equivalent of an exam or a review. The purpose of a W5 service is to manage the process of getting a doctor or other professional to conduct the examination or review and deliver their findings to you. The final outcome of a W5 service may be the findings report to you from the doctor or the finished report from you to the client.
A case may require the services of one or more doctors. For example, the insurance company may require the opinion of both a chiropractor and a neurologist. To make this happen you will have to engage a chiropractor and also engage a neurologist. Since each of these doctors will be providing an individually scheduled service you will need to add two services onto the case, one for each doctor.
In order for the doctor or other professional (W5 refers to this person as the service provider) to do their job you obviously have to book their time. W5 calls this “Setting an Appointment”. For an examination the “appointment” is the actual date and time that the service provider will interview or examine the claimant. For a review the “appointment” is normally the date that you made the booking OR the date that you expect the service provider to start the review.
For an examination service an appointment will have one of three outcomes; the claimant showed and the examination was completed, the examination was cancelled or the claimant never showed up for the examination. Each of these outcomes may (but not necessarily must) result in charge to the client (revenue) as well as a charge from the service provider (cost). It is possible that as part of the examination you needed to hire an interpreter and or a taxi. These extra items may also (but not necessarily must) result in a charge to the client (revenue) as well as a charge from the extra service provider (cost).
For a review service an appointment will have one of two outcomes; the review was completed or the review was cancelled. Each of these outcomes may (but not necessarily must) result in charge to the client (revenue) as well as a charge from the service provider (cost). Generally there are no extra items involved.
As you can see, the outcome of an appointment may result in one or more charges.
If the appointment was not completed then a new appointment may have to be scheduled. This “rescheduling” process may be repeated until either a successful completion of an appointment occurs or until the client cancels the service.
Therefore, it is possible that a single service will have one or more appointments. If there is more than one appointment on a service then there can only be one appointment (the final appointment) that is a successfully completed appointment. All other appointments would have been cancelled or no shows.
The above structure description would look something like this:
Clients claim #1234 = your case #10020
Your Case #10020
Service #1 – Chiropractic Examination
Appointment for December 5 @ 10am – claimant cancelled on December 1
(no charges were applied)
Appointment rescheduled for December 11 @ 10am – claimant no showed
● No Show fee of $200.00 billed to client
● No Show fee of $150.00 paid to doctor
Appointment rescheduled for December 16 @ 10am – claimant showed
● Examination fee of $500.00 billed to client
● Examination fee of $400.00 paid to doctor
Service #2 – Neurology Examination
Appointment for December 14 @ 10am – claimant showed
● Examination fee of $1,500.00 billed to client
● Examination fee of $1,000.00 paid to doctor
Service #3 – Psychology Review
Appointment for December 14 – doctor asked to reschedule
● (no charges were applied)
Appointment for December 14 @ 10am – claimant showed
● Review fee of $1,000.00 billed to client
● Review fee of $700.00 paid to doctor
Since a W5 case generally equates to a single client (insurance company, WSB, self insured employer, etc.) claim it is possible that over time you will have processed more than one case for a claimant.
In W5 we enter the claimant information just one time. Every case that you open for a given claimant will always be attached to that one claimant entry. This means that W5 can always provide a complete history of cases for a given claimant. This is true even if you have done cases for multiple claimants all with the exact same name (I.E.: John Smith) but who are actually completely different persons.
It sometimes happens that you will do more than one case for a specific claimant but that claimant has changed address (or changes their name) between cases. W5 allows you to simply locate the claimant at their previous address (or name) and create a new “version” of that person at their new address or with their new name. You can do this any number of times and W5 will be able to track the case history for this person across all of their address and name changes.
It is also possible that a person who was a claimant on one case may end up as the insured on another case (or vise-versa). The same approach applies here as it does for a claimant. In W5 you simply search for a person and it doesn’t matter whether they were a claimant or insured they can be found and attached to a case.
Although we have referred to these people as claimants or insured’s you can define new “roles” for people on a case.
Generally speaking, W5 has a number of predefined roles as follows:
Roles from whom you receive cases, to whom you send reports and/or invoices
Client, Insurance company, adjusting firm, employer:
Legal firm, Defense Attorney, Plaintiff Attorney:
All firms that serve similar purposes
Roles involving persons other than “clients and attorneys”.
A workflow is a concept within W5 that allows you to describe what work and decisions go into a given process. The process can be as simple as preparing a client invoice or as complex as running a requested service from start to finish.
A workflow consists of a series of steps plus a collection of step transition definitions. The steps in a workflow are usually arranged in the general sequence in which they must be accomplished. A workflow can include required steps and optional steps. Optional steps are usually things such as “Reschedule Appointment” and represent work or states that might not always occur. For example, during the course of an average “No Fault IME examination service” the claimant might actually show up for the very first appointment that you book. This means that there will not be a need to reschedule the appointment. However, if the claimant no shows on the appointment then you will need the opportunity to reschedule and this specific requirement to reschedule could be represented by the “Reschedule Appointment” step.
A workflow step represents a unit of work within the overall process and/or a current state of the process. A “unit of work” would be something like “Prepare Appointment Notification Letters”. This is clearly some work that must be accomplished in order for the step to be considered “done”. However, it also identifies that while the process is at this step that the implied process status or “state” is “waiting for someone to (Prepare Appointment Notification Letters)”. A “state” would be something like “Awaiting Appointment”. This says that the process is waiting for some event to occur (the event will almost always be something that is external to the workflow itself).
A “transition” represents an action that is taken or a decision that is made. The action or decision is either by an internal staff member or by an external entity (such as a doctor, lawyer, adjuster, claimant, etc.). By applying a transition to a workflow we are telling W5 one of the following:
● Some work has been completed (action)
● Some work has been attempted (action)
● A decision has been made
● We have received something that we were waiting for (action)
● We have dispatched something that someone else is waiting for (action)
A transition will usually (but does not have to) result in moving the workflow from one step to another step. The movement from one step to another step is often from one step to the next sequential step in the workflow but this does not always have to be the case. You can define a transition that will move from the current step to any other step forwards or backwards within the workflow.
A transition that does not move the workflow to a different step is usually used as an opportunity to record information about the current state of the workflow without changing the status of the workflow itself. For example, while at step “Confirm Appointment with Claimant” you may have called the claimant but no one answered the phone. You want to record the fact that the attempt was made to contact the claimant but the workflow needs to stay at that step because you haven’t actually received a definitive confirmation. To accomplish this you would define a transition like “Attempted Contact with Claimant” and as part of the definition you would require that the user enter a note wherein they can say that they called the claimant and no one answered the phone. This transition would be marked as “non-transitional” which literally means the transition doesn’t move the workflow anywhere.
As part of the definition of a transition, you can identify specific things that the user must (or may) do before they should proceed with the transition. You can require (or request) that the user do things such as:
● Make a note on the file
● Create one or more documents from document templates
● Upload one or more documents (browse, scan)
● Create a charge to the client
● Assign a service provider (doctor)
● Set an appointment with the service provider
● Add another workflow to the file
● Update some other workflow already attached the file
● Schedule an event or reminder in the W5 calendar
● Record that a “well known” user definable action/event has occurred
Workflows are what W5 uses to give life to a case and to each of the services on a case.
A given case will have exactly one workflow that controls it. Generally, all of the different types of cases (i.e.: No Fault, Workers Compensation, LTD, etc.) can be managed using a single workflow definition. However, that depends upon how your organization handles the different case types so if you perform sufficiently different tasks when managing one case type versus another case type then you will want to consider defining a different workflow for the different case types.
A given service will have exactly one workflow that controls it. Generally, services of similar type are handled by a workflow defined for that type. For example, IME services involve examinations and may be collectively handled by an IME service workflow while Review services such as peer review, record review and addendum do not involve examinations and have a generally simpler workflow. It is not normally required that workflow definitions in any way reflect or are affected by the specialty involved for a service.
One of the primary considerations for every workflow is how simple can you make it while still preserving all of the essential elements (work, status, actions, decisions).
While each case and each service will each have a “controlling” workflow other workflows can also be attached. These other workflows always represent activities that run concurrently with the “controlling” workflow and which do not belong in the mainstream process or cannot be easily accommodated in the mainstream process.
While a workflow by itself identifies the “how to” about a process it doesn’t specify the “when” other than what is implied in the “this after that” ordering of steps. That means of course that the workflows don’t have the information that they need to help you perform the services and deliver the final product – your report, in the timeframe that will meet statutes and satisfy client timing requirements.
So why doesn’t the workflow allow you to specify timing? The reason is this; while a group of common types of services may be handled by a single workflow definition (that is to say that they all run through the same steps) there may be statute or operational differences in how long you have to deliver the report if the service is part of one case type versus another case type or conducted in one jurisdiction (venue) versus another. And to complicate the issue even further, your clients may occasionally differ in the time constraints that they place upon you for certain types of services.
For example, an “IME examination service” on a “No Fault” case type may be allowed to take a much longer time before the report is delivered to the client than the same service on a “Workers Compensation” case type as may be dictated by statutes. Or, that same service conducted in New York may have different appointment scheduling time constraints than if it were conducted in California. And finally, client XYZ requires that you have booked an exam within 24 hours of receiving the referral while everyone else is happy with 48 hours.
Rather than defining numerous workflows where they all have the same elements but different timing it is far simpler to define different sets of timing rules and tell W5 how to find and apply the correct set of timing rules to a given workflow. A set of timing rules is called a “timeline” in W5.
A timeline consists of the following key dates:
● The referral date (when did you receive the case or service)
● The start date (when does the “clock” start for the case or service)
● The appointment date for the service
● The report due date for the service (when is the report due back to you from the doctor)
● The report deadline date for the service (when is the report due to the client from you)
So how does W5 know what timeline to use? When we define a timeline we indicate under what circumstances it may be used by answering the following questions:
● Can it be used for any client or a specific client
● Can it be used for any Case type or a specific Case type
● Can it be used for any Service type or a specific Service type
● Can it be used for any Venue or a specific Venue
● Can it be used for any Service or a specific Service
When you add a service onto a case W5 will immediately select a controlling workflow for that service using a similar set of criteria as described above and create a workflow process attached to that service.
W5 will then select the most appropriate timeline using the set of criteria described above and use the key points to set the appropriate “no later than” dates. The service starts out with a well-defined lifetime.
The rules for a timeline may specify that the report due and report deadline dates are calculated using either the start date or appointment date as a base. This means that as these things change on a service that those two key dates will automatically be recalculated. Therefore, when basing the dates on the appointment date, report due and report deadline will not be available as they have not yet been calculated.
In the real world things happen that muck up our nicely ordered timeline necessitating delays or shortcuts to our well thought out workflow. For this reason, while the timeline is used to set the report due and deadline dates in our workflow the user can make override the dates as needed.
It is important that every workflow be reviewed (after a timeline has been applied or the workflow dates have been adjusted) to ensure that you are not violating time constraints whether they are imposed by statute, operational parameters or client demands without the appropriate permissions to do so.
You can think of a key point as an important time sensitive step in a workflow. For example, the following are typically the common time sensitive steps;
For examination type workflows;
● Exam scheduling
● Notification to claimant and/or plaintiff attorney of exam date(s)
● Receiving the report from the service provider (doctor)
● Sending the report to the client
For a review type workflows;
● Booking a service provider (doctor)
● Receiving the report from the service provider
● Sending the report to the client
While it is more common that different timelines may be applied to the same workflow, it may be that a given timeline may be applied to more than one workflow definition. Therefore, we cannot simply say that a given key point applies to step #X in any particular workflow. For example, in one workflow the step where we receive the report from the doctor may be step #7 while in another similar workflow it may be step #9. These two workflows may be able to use the exact same timeline even though the second workflow has a few more elements than the first.
To accommodate this circumstance, we define each key point in a workflow with a key point identifier (called a “user defined step”) and then mark a step in the workflow definition with that key point identifier. In our example, we could define a key point in that workflow as being the “receive report” key point and then on step #7 in the first workflow we would add the key point “receive report” and on step #9 in the second workflow we would also add the key point “receive report”. In this way we don’t care where the step is in any workflow because we can always find the step marked as the “receive report” key point.
Key points allow W5 to collect information about the status of services based upon whether or not they are at or have completed a given time sensitive step.
Typical performance metrics measure how long it takes to process a service through its various key points. Since key points are completely definable by you, you can set up whatever key points you need and then derive performance statistics from them.
While a key point is a measuring point, it is not by itself a measurement. In order to acquire real time-lapse data we need to be able to record the date/time that a given key point has been achieved in a workflow. To do this we use “User Defined Actions” which can represent any of the following:
● Arrival at key point
● Execution of a key point
● Departure from a key point
● Other key point actions that you might wish to record
We can append these key point actions to workflow transitions which will then cause W5 to capture the date/time information that is needed to build performance metrics reports. For example, you may define an action that records when a report is received from the doctor and then append that action to the workflow transition action “Report received”. When the doctor’s report arrives you would go to the workflow and take the workflow transition action “report received” which will automatically record the key point action “REPORT RECEIVED”. You can now know how long it took the doctor to get the report to you and can generate an analysis of doctor reporting timeliness.