Category: Simple Concepts by Bill Zachry

Executive Summary The workers' compensation industry focuses on caseloads as a primary way to manage expenses. Claims administration, in the insurance vernacular, is Unallocated Loss Adjustment Expense (ULAE). This paper's primary premise is that the Workers’ Compensation industry needs to focus on reducing loss rather than managing ULAE expenses as a primary goal. The second premise of this paper is that claims administrators are focused on static claim caseloads instead…

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From a property insurance standpoint, a Highly Protected Risk (HPR) is a property that highly specialized property insurance underwriters have determined to be subject to a lower-than-normal probability of loss by virtue of its fire-resistive construction, limited exposure from onsite and offsite hazards, specialized fire protection equipment, abundant source of water for firefighting purposes, support from emergency responders and management’s commitment to fire prevention and loss control. HPR is an underwriting designation…

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This paper provides insight into how to use Subrosa to improve claims results appropriately.  Introduction The rose, as a symbol of secrecy, has an ancient history. The Latin phrase Subrosa (sub-rosa) means "under the rose." It is used in English to denote secrecy or confidentiality. Subrosa in workers’ compensation is the term used to denote “undercover investigation.”  Subrosa has been used as an essential tool to fight insurance fraud and as a…

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Like most of us, I learned the wrong negotiation fundamentals from my family. When I was a small boy, I knew that if I asked for something from my father and he said, “Go ask your mom,” it was a no for him, but I still had a chance. “Please, please, please!” was the preferred technique.  Negotiating was not part of our family culture so I was somewhat handicapped when…

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Most claims administration operations strive for consistency and accuracy in benefit provision. They also work hard to achieve these results with a low cost of claims. To accomplish this, they develop and establish policies and procedures for claims handling, hire and promote staff, and audit for compliance. Yet, within many claims operations (insurance companies, self-administered, and TPAs), their results significantly differ by claims office. Why? Usually, the difference in results…

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Integrating artificial intelligence (AI) into the workplace, the Workers' Compensation insurance system and the injury prevention process have greatly increased privacy concerns. While the United States Constitution does not explicitly enumerate privacy rights, the Supreme Court has inferred privacy as a fundamental right from interpretations of constitutional amendments. The advent of AI-powered technologies, such as facial recognition software and profiling, has raised questions concerning privacy infringement and algorithmic biases. Inaccuracies…

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“They did not give me the promotion! I just got hoarded.” "Employee hoarding" is a term used to describe situations where employers (supervisors, managers, VPs, HR, and entire companies) resist promoting qualified employees because they fear the consequences of leaving a crucial position vacant. Throughout my career, I have seen many claims and underwriting departments hoard skilled employees because there were no apparent replacements and because the employee being hoarded…

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"Call the doctor and let them know if we are going to authorize the surgery," said a Claims Supervisor to an examiner on the job four-days (who had only one physiology semester in high school). "I have never made a medical decision in my entire career," said a California WCAB Presiding Judge who had ordered the approval of the fourth back surgery when the consulting physician said the surgery was "inappropriate." I have seen…

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In the world of workers' compensation, there is always so much to learn about injury and treatment. Many claims examiners may assume they understand medicine, but it took me four decades within the system before I learned about Kinesiophobia. Once introduced to this concept, I was amazed at how well it explained some of the barriers that injured workers face during their journey to recovery from work-related injuries. It also…

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Once upon a time in the realm of medical care, a curious phenomenon emerged – the emergence of "Doctor Google" and his faithful sidekick, "Doctor Confirmation Bias." Many treating physicians found themselves confronted by patients who had already consulted the omniscient Doctor Google and received a diagnosis confirmed by the ever-loyal Doctor Confirmation Bias. The trouble with Doctor Google? He had a penchant for offering a menu of diagnoses, leaving…

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