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Affordable Care Act (ACA) Impact on WC Case Shifting – Live WCRI


Affordable Care Act (ACA) Impact on The Future of WC

WCRI – Affordable Care Act (ACA) Impact on WC – Case Shifting was presented by Dr. Richard Victor– the outgoing Director of WCRI. A very popular question that WCRI receives very often.

Picture of Doctor Hand Touching Affordable Care Act Sign on Virtual Screen

Whether or not the Affordable Care Act as a cost shift from health to WC with the ACA  generating these additional WC claims.

Study by Dr. Dulcamin (?) – Shipyards – Indicated Cost Shifting by HMO’s to WC, as the amount of HMO’s covered shipyard workers, the amount of WC claims increased substantially.

The central part of the ACA’s is ACO’s – Accountable Care Organizations

ACO is basically a network of medical providers that work together in a network to provide care.

Fee for Services vs. Capitated vs. Workers Comp

Fee for services has no motivational aspect to increase WC as ACO’s due as they will end up paying less than Fee For Service or WC.

Accident treatment by Dr. heavily relies on the work relatedness as assessed by the Dr.

Capitation will likely generate claims-shifting due to higher fees paid by WC.

The states where capitation is common there has been a 30% increase in soft-tissue (30%).   That is a significant number.   States where there is no capitation – there was a 10% reduction in WC soft tissue industries

Interesting comparison

  • Capitation – WC Soft tissue injuries up 30%
  • No Capitation- WC Soft tissue injuries down 10%

Fewer workers enrolled in capitated plans –  surprising fact

  • Year 2000 – Almost 30%
  • Year 2013- Less than 15%

High deductible plans (i.e. $2,000)

Has reached 35% of all workers – may have heavy cost shifting if workers has to choose between Workers Comp- first dollar paid or eating a $2,000 deductible.

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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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