Anne Kirby – Chief Operating
Officer, Rising Medical Solutions
As a business leader in the workers’ compensation domain, Anne is a leading consultant on a variety of projects related to workers’ compensation and health care. During her career, she has spearheaded various operational roles in growing territory and national expansion in the managed care field.
Her specialties include case management and utilization review, bill review, physician network development, and workers’ compensation pharmacy products, among others. In this interview, Anne talks to me about her unexpected start in this field and the unique business aspects of Rising Medical Solutions that are paving the way for better opportunities in the healthcare domain.
Starting Out in the Workers’ Compensation Domain
Anne comes from a family of teachers and with the same career path in mind, she entered college. It was during her academic years that she gained experience working for four pediatricians when an opportunity arose.
A physician approached Anne for help establishing their private practice with an offer for a complete recommendation in return. Anne took up the challenge and never looked back. She would go on rounds every day, learned about evaluating patients, did x-rays, took blood and performed cardiograms which made her realize that this is where her passion lies. After college, Anne pursued this field by attending nursing school and then went to Mass General to get as much experience as possible. She worked there for a couple of years on a medical floor before heading over to Sidney Farber Cancer Institute where they were just starting bone marrow transplants.
‘There was a huge learning curve and pioneering work being done by the team there. But the intensity and hours took their toll and I heard about two people who were starting a managed care company in workers’ comp. I had no idea what that was but it sounded kind of interesting and I interviewed and that was it.’
At CRA, Anne was one of the first full time employees. Recalling signing up her first account, Anne says that the CEO and president both knew many customers as they had worked in the industry before. They would visit those customers and ask them whether they had any cases available and then introduce Anne as their case manager.
Initially, Anne signed up three customers, each of them with a different backstory. One of them had no idea about the company and was also quite resistant to using the services offered. This is when Anne realized that this domain is not about just starting a program but taking it step by step and forming relationships. Her focus was on engaging people in a conversation and identifying critical aspects where they may need help.
‘My approach was, ” I just want to come in and meet you and understand what your needs are and nothing else. I don’t want to sell you anything, I just want to understand how you operate here, what are the things that work for you, what are the things that don’t work.”’
Exploring New Opportunities
After her experience with CRA and Concentra, Anne left the company to build out case management software for the industry. It was based on a bidding system which focused on finding the best case manager to handle a particular case. The product was before its time and the industry was not quite ready for that yet, although there are multiple bidding software companies available today.
In addition, through various RFPs, Anne and her team built out a claim system for liability claims. They set up various programs for technology solutions for smaller customers and then built out an application for UR software. They eventually joined a company and sold the rights of their creation to that company. The product is now part of a whole corporate program which moved into the healthcare arena and away from workers’ compensation at which point Anne moved into consulting at BlueMat Solutions.
Over her career, Anne had managed all of the services that are part of the daily operations of a managed care company such as peer reviews, IME reviews, liability reviews, etc. One of the main reasons she chose to focus on UR at Rising Medical Solutions was a huge need for UR services in California which had enabling legislation.
Managing the providers for IMES, peer reviews and liability reviews is a very different business which involves doing the credentialing, following up, making sure they are in the right geographic area, making sure that they have the right licensure, and checking national provider databases. The company believed their customers often had established relationships with those companies and so it made more sense to focus on the platform for UR that people could actually access and include the full service set.
‘This way we can plug and play with any other player, but you need to have that platform to pull that basic information into. Customers can come through Rising as a marketplace to access any of these services, but we do not have to be in all of those individual businesses.’
Current Business Structure and Organization
Her expertise in UR software played a significant role in Anne landing a job with Rising Medical Solutions. After 9/11, Anne recalls they faced several challenges with their services. Jason Beans, whom she knew from her previous job, was the CEO and he reached out to her for UR software services. Over time and multiple projects, they offered Anne her a position with the company itself.
Talking about the business strategy at Rising Medical Solutions, Anne talks about their platform that enables all of the data. As a bill review provider, they have a huge amount of transaction data. And, if they are providing the case management or the utilization review or any kind of early intervention program, they also have all of that information within their system.
‘One of the things that is very nice about the Rising system is that everyone uses the same platform. All of our employees use the same platform regardless of the service and customers through our portal can see their cases and the activities as they are taking place.’
This common platform allows for a variety of analytics that enables the team to gauge which cases need priority focus. This ability adds to the system’s value. The company also has an operational unit that enables them to refer out to various partners. Even though they do not provide every single service, they can provide customers with valuable links to those services which speeds time to referral and ultimately saves dollars which is an important service.
The healthcare domain is constantly evolving with new policies and regulations changing. Staying updated is crucial and for that Anne reveals that when she started consulting, she created a national jurisdictional compliance database where she updated the rules of every single state every quarter. This offered her valuable clarity regarding what is written in the books versus what the actual practice is. She also developed relationships with many state employees and reviewed with various sources including the Workers’ Comp Research Institute. She also worked with an Australian company to develop technology solutions for guidelines and an application which she licensed to companies with quarterly updates which provided a good structure for staying up to date with the latest changes.
Pandemic and Remote-Working Challenges
The sudden onslaught of the pandemic had proved challenging for everyone. Companies had to shift to remote working overnight, which was difficult for several organizations that lacked the necessary resources to do so.
At Rising Medical Solutions, the company already had a plan in hand. Anne mentions that the year before COVID-19 hit, the company location had experienced a polar vortex where people couldn’t go outside because it was 35 degrees below zero.
The company had to get people home very quickly and that time proved a great learning experience on what worked and what didn’t work. When the pandemic hit, the company already had a roadmap which they were able to adopt instantly.
Additionally, the company had just invested in a new phone system which was a big help as it didn’t matter as employees could answer their calls from anywhere. They also focused on information security, accountability and initiated two-factor identification for all. These steps helped the company instantly cope with the pandemic challenges.
Standout Moments as a Business Leader
For Anne, the most significant standout moments were having experiences working in companies that were adding multiple products to their skill sets. It always marked progress and it promoted innovation which were two things Anne found very exciting.
Anne recalls when she first started in managed care, she was the first full-time employee and when she left there were about 9000 employees. Also, when she left the comfort of the large organization and co-founded a software start-up to build out a case management system that focused on technology efforts rather than providing services, it served as an invaluable learning experience.
‘Through that process, I realized I was a better builder than a maintainer and this became an important piece to learn for the next half of my career, that building piece really energized me.’
Talking about Rising Medical Solutions, Anne feels pride at their investment in analytics and technology. She believes it has added immense value to their customers, their partners, and their staff. Their analytics drive everything that they do. The company has dashboards available every minute of the day which has made a huge impact on the organization. The technology platform is always evolving and is extremely flexible making it functional for a wide array of customers.
The other aspect of pride for Anne is the company’s success in making the transition from a bill review company to a managed care company. Historically, many of the companies that are managed care companies in the workers’ comp industry began as case management companies and they became an arm of an insurance company or a third-party administrator, and then they added in bill review services. Rising did it a little bit differently. They started as a high dollar cost management company on very high bills, then became a bill review company, and then morphed into the case management and utilization review and early intervention services after the fact.
‘It is a different model from other companies, but one of the things we have learned by utilizing our analytics is where to focus our energies.’
Overcoming Challenges in This Domain
For Anne, trying to build a case management application in the middle of the economic downturn in early 2000s and the impact of 9/11 on the insurance companies, in general, was very challenging. Insurance companies were trying to evaluate what their losses were, to figure out the impact on their margins and loss ratios, and they could not focus on utilizing any new services.
‘The thing that I learned from that experience was that you learn way more from the bad times than you do from the good times and it is “how you respond to those bad times” has the biggest impact on the result.’
Top Philosophies and Core Values in Business
‘One of the things that I always think about is that everybody talks about how you make sales to customers and what I would say is to shop for your customers.’
For companies, it is important to understand where their sweet spot is, understand how they can have aligned incentives with their customers, and understand the real meaning of a partnership. If a company can do these things, they will find the right customers.
Customers are not one size fits all, and neither are managed care companies. This is why integration is very important as part of that whole process. Many companies do not integrate all their services into one bundle, but the ones that get it right focus on integration. To achieve value, it is important to figure out ways of linking those pieces together.
The other thing Anne believes in is when talking to customers; the focus should be on the cost of the claim rather than the unit price of each service. In the last 5 years or 10 years, there is a focus on procurement and getting the price as low as possible, but the focus should be on the objectives of the program and then figuring out how it can impact the cost of the claim.
The last piece is really to just align the incentives. Ensure that the providers and nurses get involved on day one to get those claims resolved early.
‘The company’s early intervention program called Rising Ultimate has had a huge impact. It is one flat fee for a year and so if you look at it from that perspective the focus is on us getting the results rather than the billable hours of the services.’
Advice for Newcomers Looking to Start a Career in the Workers’ Compensation Domain
Anne believes that there are still opportunities here and it is a great field to work in. This industry offers a great opportunity to spend time with people, to help people grow, to help people develop new products, and to innovate. There is still room to link many different services and to figure out what is the next best thing. One trend today is that a lot of insurance companies are outsourcing all the things that they don’t feel they need to worry about anymore and making somebody else accountable for that. There are many opportunities to be able to do those things in the meantime.
Vision for Future of the Industry
An important point, according to Anne is a continued focus to remove cost from the system. She believes there are some services such as a fee-based services in case management that just drives cost and does not always provide the best result.
To achieve this, companies need to align their incentives. They need to identify how to create relationships with customers to make sure that the right results are achieved for the right price.
‘One of the things that I always say to our team is that we have to shop for the right customers. We are not necessarily the best match for every customer and that is okay, but there are ways to help our customers find the greatest value.’
For companies and professionals looking to remain successful in this domain or business in general, Anne lists spending time with people and helping them grow at the top. For someone in a leadership position, focus on removing the barriers to the team’s success. Identify the areas as a leader that can help make people more successful, be persistent, pick up the phone, and smartly outwork competitors.
‘You can have a slow, steady growth which is what Rising had by focusing on cost and the result. If you can grow those happy customers and keep those happy customers, you will be fine.’
Leadership Lessons Learned Over the Course of Life
‘I have a rule that I would never say anything about anyone that I wouldn’t say or haven’t said to that person.’
For Anne, it is important to be fair to people, be positive, and be persistent. Focus on people and relationships. The content is important, but content can be learned from anybody but relationships cannot be developed unless they are genuine.