Claims in one sentence

• Tell me in a sentence how your team defines a successful workers compensation claim outcome.
• How many open lost time claims does your team manage in a typical month? Options: Fewer than 50, 50 to 199, 200 to 499, 500 or more, Unsure
• Walk me through the last claim that surprised you with its cost or duration, what specifically stood out?
• Who on your team is the primary decision maker for changes to claim workflows and policy? Options: Risk manager, Claims director, VP of claims, CFO/Finance, Legal counsel, Other
• If the seller could shorten your average indemnity duration by 20% tomorrow, what internal barrier would still prevent you from moving forward this quarter?

Where the workflow actually leaks time and money

• Point to the single step in your claim workflow that creates the most delay or cost, and explain why.
• How often do early clinical reviews occur within 72 hours of injury reporting? Options: Always (>90%), Often (50 to 90%), Sometimes (20 to 50%), Rarely (<20%), Never
• When a claim escalates to litigation, how long is it from injury to counsel involvement on average? Options: Within 30 days, 31 to 90 days, 91 to 180 days, More than 180 days, Varies widely
• Which cost drivers currently dominate medical spend for your population? Options: Surgery and specialist fees, High-cost imaging, Chronic opioid prescribing, Extended rehab or PT, Facility/unbundled billing, Other
• Share the typical handoffs between triage, examiner, and nurse case manager, and where breakdowns most often happen.
• Which single operational failure would cause you to stop a pilot immediately?

The people who move claims, and where they get stuck

• Name the role that is first informed when a claim is reported, and how that initial ownership affects claim speed.
• Which roles on your team approve medical authorizations and within what target time do they aim to approve? Options: Claims examiner (24 to 48 hours), Claims examiner (48 to 72 hours), Medical director (clinical review), Nurse case manager first, then examiner, Other
• How many dedicated nurse case managers do you assign per 100 active claims? Options: 0 to 1, 2 to 4, 5 to 9, 10 or more, Unsure
• Tell me about a recent situation where role ambiguity slowed a return to work, and what the consequence was for cost or duration.
• Suppose your staffing model were reduced by 20%, which function losing headcount would most threaten claim outcomes? Options: Front-line examiners, Nurse case managers, Utilization review, Pharmacy management, Vocational services, Other

Clinical and pharmacy levers that change outcomes

• How much of your total medical spend last year came from opioids, repeat imaging, or elective surgery? Options: Less than 10%, 10 to 25%, 26 to 50%, More than 50%, Unsure
• Which clinical programs are active on your claims today? Options: Nurse case management, Utilization review, Pharmacy management, Physical therapy coordination, Telemedicine, Surgery vetting/management, Other
• Explain the most common clinical pathway for a typical sprain or strain claim and where costs tend to escalate.
• How quickly does pharmacy prior authorization for controlled substances typically occur in your environment? Options: Within 24 hours, 24 to 48 hours, 3 to 5 business days, Longer than 5 days, No formal PA process
• Which measurable clinical success criteria do you track at the claim level? Options: Time to first clinical contact, Return to work within target window, Reduction in opioid MME, Pain/function scores at 4 weeks, Medical spend per claim, Other
• When a clinical intervention could reduce high-cost imaging by about 30%, what would need to change for you to accept it into your standard workflow?

What's stopping faster return to work

• Which barrier most often prevents an injured worker from returning to modified duty within your target window? Options: No suitable duties at the employer, Medical restrictions exceed employer capacity, Delays in authorization, Lack of vocational support, Worker reluctance or fear, Other
• How often do employers provide modified duty within 14 days of injury in your population? Options: Almost always, Often, Sometimes, Rarely, Never
• Share an example of an employer or site where return to work consistently works well, what do they do differently?
• Which internal or external role typically negotiates light duty plans with supervisors at worksites? Options: Claims examiner, Nurse case manager, Vocational coordinator, HR at employer, Plant manager/supervisor, Other
• Would securing employer site level buy in remove the biggest blocker to faster return to work for you? Options: Yes, Maybe with additional incentives, No
• What single legal or benefit calculation issue could prevent you from implementing a faster return to work program?

Regulatory and reporting pressure points

• Which state specific reporting requirement or benefit calculation regularly forces you to slow claim processing?
• How many jurisdictions do you operate in for workers compensation? Options: 1, 2 to 5, 6 to 10, 11 to 25, More than 25
• Which reports must you produce monthly versus quarterly versus annually? Options: State mandated reports, Loss runs, Return to work metrics, Medicare reporting, Provider network utilization, Other
• Describe any recent audits or penalties that materially affected your claims operations or vendor relationships.
• If a regulatory change required an extra data field within 30 days, which internal owner could sign off and deliver it? Options: Claims operations lead, IT/Integrations, Compliance/legal, Vendor management, No clear owner, Unsure
• Is there a pending regulation or audit that could stop a vendor deployment within 90 days? Options: Yes, No, Unsure
• If you answered yes, please describe which regulation or audit and the likely timeline.

Alternatives on the table and why they might keep your business

• Given your recent claims performance, why are you considering an external partner now instead of keeping the current approach?
• Which of the following options are you actively evaluating right now? Options: Incumbent TPA or vendor, New external vendor, Insourcing to internal claims team, Pilot multiple vendors, Software only solution, Other
• What would have to be true about your current approach for you to keep it rather than move to a new vendor?
• Has anyone on your team proposed solving this without an outside partner, and if so who and what is their proposed plan?
• What top reasons would let your incumbent retain business even if a new vendor offered a lower price? Options: Existing contract terms and exit costs, Data migration complexity, Regulatory comfort with incumbent, Established provider relationships, Performance guarantees from incumbent, Other
• If our proposal matched the incumbent on price and hit your indemnity reduction target, what would still stop a change this quarter?

Can we actually connect to your systems and data

• If you could only integrate with three of your systems during onboarding, which three would be non negotiable? Options: Claims management system, HR and payroll, Pharmacy benefit manager, Electronic medical records, Billing and payment system, Provider network directory, Other
• Which internal team owns your claims system API and can they commit resources in the next 30 days? Options: Yes, named owner available, Yes, but limited availability, No, requires procurement, Unsure
• How clean and accessible is the historical claims data you would share for pilot analysis? Options: Ready and mapped, Partially cleaned, Raw and needs work, Unavailable
• Which data fields are often missing or poor quality in your claims exports? Options: Injury coding and narrative, Provider invoicing, Return to work dates, Medication lists and MME, Adjuster notes and contact info, Other
• Do you host vendor integrations behind strict firewalls that require VPN or on site access? Options: Yes, both VPN and on site, Yes, VPN only, No, Unsure
• Are there contractual or IT approvals that must be signed before an integration can begin? Options: Yes, No, Unsure
• If yes, who are the approvers and what is the typical approval lead time?

Measures that will actually define success

• Which single KPI, if improved by the pilot, would make your leadership sign off immediately?
• Which of these KPIs does leadership review monthly? Options: Cost per claim, Average indemnity duration, Return to work rate, Attorney involvement rate, Medical spend per claim, Claims frequency
• What is your current target for average indemnity duration that you would consider acceptable? Options: Less than 14 days, 14 to 30 days, 31 to 90 days, More than 90 days, No formal target
• How frequently would you want outcome reviews during a pilot to evaluate success? Options: Weekly, Biweekly, Monthly, Quarterly
• Who must sign the pilot acceptance criteria for you to proceed to full deployment? Options: VP of claims, CFO/Finance, Legal counsel, Risk manager, IT lead, Other

Next steps, timing, and decisive gates

• If the pilot proves the outcomes you expect, what internal process would allow you to sign a commercial agreement within 30 days?
• What is your ideal project start date for a pilot? Options: Immediately, Within 30 days, 30 to 60 days, 60 to 90 days, Unsure
• Who needs to attend a 60 minute alignment call to approve scope and timeline? Options: Claims director, VP of claims, IT/integrations lead, HR or employer relations, Legal counsel, Finance/CFO
• Which budget cycle or procurement windows could constrain your ability to sign in the next 6 months? Options: Funds available now, Next quarter budget, Annual budget only, Procurement lead time required, Unsure
• What outstanding questions or risks would make you pause before committing to a pilot?

• Solution Experience — Clinical & Return-to-Work Walkthrough

• Provide three representative, anonymized claim scenarios with medical timelines, bill totals, and current handling notes for modeling.
• Confirm the current state and its cost to your team
• You confirm that the demonstrated workflows materially reduce the clinical and pharmacy drivers of medical cost for the shown claim scenarios.
• Seller to run the provided scenarios through clinical, utilization review, and pharmacy models and deliver a claim-level impact summary with projected cost delta and expected days-to-return-to-work before the next session.
• You confirm that the demonstrated return-to-work orchestration shortens expected indemnity duration for the shown scenario types.
• Proof step, Scenario A — clinical intervention applied
• You and the seller agree on the remaining evidence and target KPIs required to include these services in a pilot or contract.
• Proof step, Scenario B — utilization review and pharmacy controls
• Jointly define target KPIs and acceptance thresholds for a pilot, including target reduction in medical cost per claim, target reduction in indemnity days, and acceptable litigation rate.
• Proof step, Scenario C — return-to-work orchestration
• Validate the future state explicitly

• Solution Experience — Clinical & Return-to-Work Walkthrough
• Solution Experience Deck
• Solution Brief — Clinical Intervention & Return-to-Work

• meeting
• slides
• document

• 24/7 injury reporting and triage
• Dedicated claims examiner management
• Nurse case management
• Utilization review for medical necessity
• Pharmacy benefit management with opioid controls
• Return-to-work program implementation
• Medical bill review and negotiation
• Provider network access and fee schedule management
• Indemnity payment processing and benefit calculation
• Medicare Set-Aside (MSA) administration
• Subrogation identification and recovery
• Independent medical exam (IME) coordination
• Predictive analytics for claim severity and litigation risk
• Litigation coordination and attorney liaison

24/7 injury reporting and triage

• Which channels should you enable for 24/7 injury intake (phone hotline, mobile app, employer portal, secure fax)? Options: Phone hotline, Mobile app, Employer portal, Secure fax, Other
• Do you require after-hours nurse triage with clinical documentation posted to your claims system? Options: Yes, No
• How many after-hours intake events per month should staffing assume based on your historical claim run-rate? Options: Less than 50, 50-200, 200-500, More than 500
• Provide the exact claim intake fields your current claims system requires (for example: claim number, employer code, date of injury, body part, initial severity).
• Specify any state-specific immediate reporting forms or statutory timelines that the intake workflow must auto-generate (list state codes and forms).

Dedicated claims examiner management

• List the jurisdictions by state code where you require dedicated examiner coverage.
• Select whether you require a named primary examiner per claim, a pooled-assignment model, or a hybrid approach. Options: Named primary examiner, Pooled assignment, Hybrid
• Indicate your target examiner-to-open-claim ratio for steady-state caseload planning. Options: 1:50, 1:75, 1:100, Custom
• Who in your organization approves examiner authority for reserve changes, medical stop-loss, and litigation referrals (title or role)?
• For claims with total incurred over $50,000, should examiners escalate to a centralized specialty clinical or litigation team? Options: Yes, No, Case-by-case

Nurse case management

• Which clinical acuity tiers (low, moderate, high, catastrophic) should automatically trigger nurse case management assignment? Options: Low, Moderate, High, Catastrophic
• Do you require telephonic-only nursing, in-person nurse visits, or a hybrid nurse case management model? Options: Telephonic only, In-person only, Hybrid
• Specify the required deliverables from the nurse case manager per claim (for example: initial care plan, weekly progress notes, RTW plan, coordination logs).
• Indicate any state nurse practice act constraints or licensure requirements we must observe by state code for in-person nursing services.
• Are there preferred medical specialties you want nurse case managers to escalate to for IME or specialty referral (for example: orthopedics, occupational medicine)? Options: Orthopedics, Occupational medicine, Pain management, Psychiatry, Other

Utilization review for medical necessity

• Which utilization review criteria must govern decisions in your jurisdictions (state UR rules, Official Disability Guidelines (ODG), or other named standards)? Options: State UR rules, ODG, Other clinical guideline
• Choose the UR review types you require: prospective, concurrent, retrospective, or a combination. Options: Prospective, Concurrent, Retrospective, Prospective and Concurrent
• Specify required turnaround time thresholds for UR decisions by case type (for example: 24 hours for expedited, 7 days for routine).
• Indicate whether clinical peer-to-peer review with a board-certified specialist is required for denials in your program. Options: Yes, No
• Provide the integration method so UR dispositions are visible in your claims system (API endpoint, HL7 interface, secure SFTP file drop). Options: API endpoint, HL7 interface, Secure SFTP, Manual upload

Pharmacy benefit management with opioid controls

• Which opioid utilization controls must be enforced (for example: morphine milligram equivalents limits, prior authorization, step therapy)? Options: MME limits, Prior authorization, Step therapy, Lock-in program, Other
• Do you prefer a closed formulary, a preferred list with utilization controls, or an open formulary with controls? Options: Closed formulary, Preferred list with controls, Open formulary with controls
• Specify the pharmacy claims file fields you will provide for PBM actions (for example: prescriber NPI, patient DOB, NDC, days supply, MME/day).
• Indicate whether real-time Prescription Drug Monitoring Program (PDMP) checks are required at point of prescribing, batch checks, or not required. Options: Real-time PDMP, Daily batch PDMP, Not required
• Are medication-assisted treatment (MAT) referral and coordination services required for opioid dependence cases? Options: Yes, No, Case-by-case

Return-to-work program implementation

• Which return-to-work models do you want enabled (for example: modified duty at employer site, third-party transitional placements, light-duty pool)? Options: Modified duty at employer site, Third-party placement, Light-duty pool, Transitional work
• Do you have existing job descriptions for modified duty tasks to map to physician work restrictions? Options: Full library available, Partial set available, No job descriptions
• Specify the target timeframe after injury within which you expect modified duty offers to be made (for example: 7 days, 14 days, 30 days). Options: 7 days, 14 days, 30 days, Custom
• Indicate whether your employer network requires a written employer work-release form or whether the treating physician note is sufficient for RTW placement. Options: Work-release form required, Treating physician note sufficient, Other
• Do you require return-to-work outcomes reported to your claims dashboard including actual return date and hours restored? Options: Yes, No

Medical bill review and negotiation

• Which baseline should the bill review apply (state fee schedule, Medicare, network-negotiated rates, or a custom schedule)? Options: State fee schedule, Medicare fee schedule, Network-negotiated rates, Custom
• Are line-item level reviews required including CPT/NDC validation and duplicate-service checks? Options: Yes, No
• Provide the dispute and appeals documentation you require when a provider contests a bill adjustment (for example: itemized bill, medical record cross-reference, peer review).
• Indicate the typical variance between billed charges and your expected allowed amounts you observe (select percentage range). Options: 0-20%, 21-40%, 41-60%, More than 60%
• Are any provider types exempt from negotiation (for example: centers of excellence, court-ordered specialists)? Options: Yes, list exemptions, No

Provider network access and fee schedule management

• List the provider network tiers or IDs you require included (for example: in-network panel, centers of excellence, ancillary providers).
• Do you require active credential verification and NPI matching before a provider is added to the panel? Options: Yes, No
• Specify whether fee schedules should be managed by state, by CPT code, or as bundled case rates. Options: State-specific fee schedule, CPT code fee schedule, Bundled case rates, Custom
• Indicate the frequency and delivery method for fee schedule updates (for example: quarterly upload, annual update, push via file). Options: Quarterly file, Annual file, On-demand via bulk file
• Are out-of-network direct-billing exceptions allowed for emergency care and if so should they auto-approve or require prior authorization above a threshold? Options: Auto-approve for emergencies, Require prior approval, No exceptions

Indemnity payment processing and benefit calculation

• Specify the wage basis and replacement ratio your jurisdiction uses for indemnity calculations (for example: gross wages, average weekly wage, statutory percentage).
• Do you require benefits to be calculated and posted automatically into your claims system, delivered as calculation reports, or both? Options: Automatic posting, Calculation reports only, Both
• Provide the acceptance criteria for payment accuracy you require (for example: 99.5% calculation accuracy against applicable state statute).
• Indicate your preferred payment methods and cadence for indemnity disbursement (for example: ACH weekly, ACH biweekly, paper check). Options: ACH weekly, ACH biweekly, Paper check
• Are there special indemnity rules for partial disability or temporary total disability we must encode into calculations? Options: Yes, No

Medicare Set-Aside (MSA) administration

• Which trigger conditions should prompt MSA assessment in your program (for example: claimant age 65+, settlement value above a threshold, Medicare enrollment)? Options: Age 65+, Settlement value threshold, Medicare enrolled, Custom
• Do you require CMS submission support for MSA approval and conditional payment recovery or only internal MSA documentation? Options: CMS submission support, Internal MSA documentation only, Case-by-case
• Provide the documentation you will supply for MSA setup (for example: historical medical records span, future treatment estimates, prescription history).
• Indicate whether you require ongoing post-settlement MSA administration such as periodic reporting and reimbursement tracking. Options: Yes, No, Case-by-case
• Are there state-specific MSA thresholds, local counsel requirements, or statute-driven differences we must follow (list state codes if applicable)?

Subrogation identification and recovery

• Describe the upstream data point you use to identify subrogation potential (for example: third-party liability flag, police report, witness statement).
• Do you require a minimum potential recovery threshold to open a subrogation file (for example: $5,000)? Options: No minimum, $1,000, $5,000, $10,000, Custom
• Which recovery pathways do you permit for subrogation matters (for example: full recovery pursuit, global settlement offset, lien negotiation)? Options: Full recovery pursuit, Global settlement offset, Lien negotiation, Other
• Provide the timeline you expect for initial subrogation assessment from date of incident (for example: 7 days, 14 days, 30 days). Options: 7 days, 14 days, 30 days, Custom
• Indicate whether coordination with outside counsel is required for high-value subrogation matters above a specified threshold. Options: Yes, above threshold, No

Independent medical exam (IME) coordination

• Do you require IME scheduling within a specific timeframe after referral (for example: 14 calendar days)? Options: 14 calendar days, 21 calendar days, As available, Custom
• Which IME specialties are most commonly required in your caseload (for example: orthopedics, neurology, psychiatry)? Options: Orthopedics, Neurology, Psychiatry, Pain management, Other
• Specify the report delivery format and required contents for IME reports (for example: structured findings, AMA guides reference, work-capacity opinion).
• Indicate whether you will accept video IMEs or require in-person examinations only. Options: Video IME allowed, In-person only, Either
• Are there state-specific IME regulations, panel requirements, or examiner qualifications we must follow (list state codes if applicable)?

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Commercial Terms / Order Form
• Service Level Agreement (SLA)
• Data Processing Agreement (DPA) and HIPAA Business Associate Addendum (BAA) (conditional)
• Regulatory and Reporting Addendum
• Claims Handling Authority Addendum
• Security and Incident Response Addendum
• Termination and Transition Plan

• Go-live Health Check (Week 1-4)
• First Measurement Review (Week 4-10)
• Acceptance Gate Decision (Around Day 90)
• Quarterly Outcome Review

• Produce a one-page quarterly outcome summary and publish it to the shared workspace.
• Produce a metric variance report with three case-level examples for each off-target metric.
• Add agreed remediation tasks to the shared backlog with target resolution dates.
• Assemble the evidence package required for the Acceptance Gate as defined in Solution Scope.
• Restate acceptance criteria and targets
• Produce a documented acceptance decision with pass/fail status for each Solution Scope criterion.
• If any criterion failed, agree a remediation and re-test plan with dates.
• Store the acceptance decision and evidence in the shared workspace for traceability.
• Publish the acceptance decision document and supporting evidence to the shared workspace.
• Create remediation tasks for failed criteria with deadlines and re-test dates in the shared backlog.
• Circulate the acceptance decision summary to all stakeholders and confirm next meeting cadence.
• Quarterly trend review
• Confirm whether quarterly trends meet expectations or require escalation.
• Reduce backlog age by closing or re-prioritizing high-impact items.
• Validate closure evidence for previously agreed remediation tasks.
• Update the shared backlog with prioritized items and target delivery quarters.
• Open investigations for any new metric regressions and set completion dates.
• Re-confirm success criteria and owners
• Deployment verified against Solution Scope checklists and owners confirmed.
• Top 3 early blockers identified with remediation dates.
• If applicable, incumbent wind-down plan recorded in the shared workspace.
• Publish the go-live verification checklist and remediation plan to the shared workspace.
• List any missing data feeds or access issues and schedule fixes with target dates.
• If replacing an incumbent, document the decommissioning and data archive status and publish evidence.
• Present first measurement data
• Decide whether early metrics are on track toward Solution Scope targets or require remediation.
• Document root causes for the top 2 metric variances and agree corrective actions.
• Confirm the timeline and evidence required for the Acceptance Gate.
• Present outcome data versus each criterion
• Operational outcomes detailed review
• Deployment and data validation
• Root-cause diagnosis
• Document pass or fail per criterion
• Early adoption and usage signals
• Shared backlog and enhancement prioritization
• Agree corrective actions
• Action tracking and closure evidence
• Capture formal acceptance decision
• Incumbent wind-down confirmation, if replacing an incumbent
• Confirm timeline to Acceptance Gate
• Open issues and blockers
• Agree next quarter priorities and metrics to monitor
• Agree remediation and re-test plan for any failed criteria
• Update shared backlog and owners
• Agree immediate remediation actions and next steps