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California Medical Review and Dispute – Blogging WCRI Conference


California Medical Review and Dispute Blogging Live WCRI Conference

California Medical review and dispute is a white hot topic amongst risk managers presently.  One of the hot sub-topics now is the amount of money charged for UR (Utilization Review) in California.

In our claims loss run analyses, we find that California ALAE Allocated Expenses to handle a claim can actually cost more than the benefits provided to the injured employee.  No other state comes close to this amount.

Picture of California Medical Review National Healthcare System

One recent estimate showed that the cost for UR was more than the medical charges themselves.   The UR charges have grown steadily over the past ten years.  The employers have to pay the final bill for the UR charges either by paying an increased premium due to the rates and a higher XMod or budgeted funds for the self insureds.

As this one is in the conference book, and there were so many great charts which covered so much great info,  I will cover this one soon.   I cannot give this section justice without reviewing the charts more closely.  I am trying to juggle doing interviews with the presenters and doing live blogging.

Some of the more interesting statistics-

  • 1% of doctors accounted for 46% of IMR (Independent Medical Reviews)
  • 50% of pharmacy benefits go to IMR – no other medical service even close

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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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