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Reforms – WCRI Conference Texas, Pennsylvania, Oregon and Florida


Reforms – WCRI Conference

Reforms – WCRI – States – Texas, Pennsylvania, Oregon and Florida presented on the effects of reforms that were enacted in each respective state.

Reforms Conference for WCRI Emblem From Web
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  • 270 insurance companies
  • 2.2 billion in direct written premiums

Texas had pre-reform-

  • High medical costs– over-utilization
  • Poor Return to Work outcomes
  • Poor access to care
  • High insurance premiums
  • Increasing Opt Out employers
  • Increasing number of medical disputes

Texas reforms

  • Used data to identify medical cost drivers
  • Built medical infrastructure similar to health insurance
  • Evidence based medicine
  • Measured outcomes

Texas solution –

  • EDI (Electronic Data)
  • Administrative Dispute Process was initiated
  • pre-authorization requirements to have more carrier involvement
  • Adopted Medicare billing structure
  • Implemented certified networks
  • Implement closed pharmacy formulary

Texas results-

  • Average medical bill per claim was reduced significantly
  • Average premiums decreased 50% since 2003
  • Less employers opting out of WC system
  • Medical disputes fell 71%
  • Access to care improved


Act 44 – four areas of reform

  • Reduce medical costs, while not affected level of care
  • Address usage charges and utilization creep
  • Addressing litigation increases and related costs
  • Address the matter of who runs the insurance marketplace

Act 44 – results

  • Medical expenditures- patterned after most state systems and Medicare
    • Employer directed care expanded to 30 days
    • Medicare based fee schedule
  • Increasing litigation 
  • Competition in the WC marketplace

Act 57

  • Medical Management
  • Benefit Management
    • Offsets – SSDI , etc.
    • Limited PPD to 500 weeks
    • Dispute Resolution Management


Reform  targets

  •  Ability to advise governor of bills that were not good for WC community.
  • Medical care improvement
  • Return to Work
  • AOE/COE – medical substantiation
  • Palliative care  limits
  • Timely Insurer benefit payments

Reform results

  • Rate reduction
  • Better medical care
  • MD and DO increased treatment, chiropractic care reduced


System Success

  • Medical bills filed and paid timely 98.5% of the time
  • Petitions filed (litigation) has decreased by 2/3
  • Actual case litigation down by 50%
  • Coalition formed – 200 companies (carriers, employers, and associations)

Legislative continuity and leadership has been stable, no recent crisis


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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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