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Automated Workers Comp Medical Only Claims Not A Solution Yet


Automated Workers Comp Medical Only Claims vs. Human Intervention

Two different presenters this month spoke on automated workers comp medical only claims.  In fairness to the presenters, I will not mention their names or companies.   Their presentations were better than most that I have seen on this subject.

picture of automated workers comp medical only claims alarm clock

The ideas of claims automation claim analytics and other “no-touch” claims adjusting, and processing have been discussed since the mid-1980s.  Unfortunately, worker’s compensation has not been able to advance as much as health or other lines of insurance since that time.

The Tick Tick Medical Only Claims

Automated Workers Comp medical only claims caught my attention in 2005 when a monopolistic state fund was using a fully automated system – even to set reserves and to send out forms, letters, and to accomplish other daily “mundane” adjuster tasks.

Two members of the Workers Comp press interviewed me on my article.  One reporter agreed with me, the other one not so much.

The system was scrapped in 2008 as the monopolistic state fund ran into many problems including being severely under-reserved on certain claims and over-reserved on many minor claims.   Overall, the fund totals seemed accurate, but the underlying financials made no sense.

The Tick Tick Medical only claims in the above subtitle came from an article I wrote many years ago as a dire warning to medical only claims adjusters, supervisors, managers, insureds, and especially self-insureds.

Any claims person will nod their head that some of the worst claims they have handled originate as minor medical claims.  Without any intervention, these claims were paid and closed with problems still existing before and after closure.

Avoid Claims Festering

Medical Automated workers comp medical only Blue stethoscope
Wikimedia Commons – Tachypnoe

Medical only claim festering(c) was a concept and keyword that I coined 15+ years ago.  In the late 1990s, I decided to start analyzing any injury, type of claim, or any variable that was most common amongst the worst claims.   The claims that reached into my claims authority level (over $75,000) had many similar characteristics.

I covered those in the Six Keys to Workers Comp Cost Savings and even wrote two manuals on them.  The one element that popped up repeatedly for the worst of the worst claims overwhelmingly started as untended medical only claims.   These claims were inherited from another TPA – they did not occur on my watch.

Why did they not occur on my watch? Each claim had a supervisor, adjuster, and medical only adjuster, along with a claims assistant all look closely at every incoming claim.   The claims processing system had a module for automated workers comp medical only claims that we never used on even one claim.

Automated Workers Comp Medical Only Claims – Solution Someday?

I have reviewed a claims processing system over the last week that may be able to at least reduce the amount of “eyes on the small claims.”   We shall see how that works out.

Also Read: Monopolistic Workers Comp Examined Further

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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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