Simple Concepts for a Complex System - William (Bill) Zachry
The top cost drivers in the system are*:
The “at risk employee”
Employer / Employee relationship
Age of the injured worker
Injuries with multiple body parts
Application first notice claims from workers’ compensation mills primarily in Southern California
*Some of these cost drivers overlap and or experience the same basic causations
To manage and reduce these costs requires engagement of the employer and treating physician to work in partnership with the claims adjuster.
51 % of workers’ compensation claims account for 1 % of the benefits paid. There should be an efficient way for these claims to go through the system with minimal administrative effort and expense. Efficiencies should include quickly and accurately identifying this cohort of claims. Prompt reporting of the claims and even faster determination of compensability. An automated authorization of evidence based medical treatment, automated payment of treatment which had been approved (elimination of bill review).
3 % of the claims account for 60 % of the expense and benefits in workers’ Compensation. Of these claims some are considered “Catastrophic” claims (quadriplegics, paraplegics, amputations, severe burns, total loss of vision, head injuries“) The rest are “sisterhood of the traveling body parts injuries” (also known as Jumper Claims). If we can id the Jumper claims within four weeks of the injury and close them within one year of the date of injury it could cut off up to 50 % of those claims costs. Which is also equal to a 20 % savings for the whole system. To do this will require a focus on finding the “at risk” employee and intervening with appropriate settlement authority to get these claims closed.