Category: Simple Concepts by Bill Zachry

"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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In the realm of business, navigating the complexities of customer interactions often involves confronting the challenge of managing 'unreasonable demands.' These demands can manifest in various forms, ranging from unrealistic timelines and requests that fall outside contractual agreements to actions that pose ethical or legal dilemmas. Today, service companies often possess greater knowledge than their customers regarding operational, legal, and ethical considerations within their industry. How service companies respond to…

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With the advent of AI-powered customer call centers the promise is of easier navigation and improved service. Many current call centers have yet to transition to this technology.    Great customer service is a primary responsibility of the CEO of every company in our industry. I firmly believe that having the senior executive of the company actively regularly (once a month on the calendar) testing the customer service call centers, would…

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When I was the GVP of Risk at Safeway we performed an analysis of our corporate culture to design a safety program that would have the opportunity to maximize the success of our goal of reducing claims frequency. The two essential traits of our corporate culture were:  1. What my boss found interesting I found fascinating  2. The company was driven by competition (comparing and competing divisions, districts, stores and even departments) …

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A containment room is a highly protected area to store flammable and combustible items in a warehouse to avoid catastrophic fires. Items such as cigarette lighters, candles and other highly flammable products are usually segregated from the rest of the warehouse in a “containment room.” Having a containment room in a distribution warehouse is part of having a warehouse that is designated as a “Highly Protected Risk.” HPR is a…

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The workers’ compensation industry faces a daunting challenge: a severe shortage of qualified claims examiners. This crisis threatens to inflate costs, delay crucial benefit decisions, and undermine the quality of claims management. By understanding the root causes and implementing proactive solutions, industry leaders can navigate this turbulent landscape and safeguard the integrity of the workers’ compensation system.Impact of Examiner Shortage: The shortage of skilled claims examiners is not merely a…

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Roger was the most knowledgeable worker's compensation claims person I ever met. He knew the labor code; he knew all the case law and how each legal opinion applied to that claim which was in his hand. He knew how to accurately and consistently reserve claims (he was exceptional with this), he knew how to audit claims, and he knew how to resolve claims.  Roger was not very tactful. He…

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Introduction   Within all claims operations, the claims manager and supervisor are responsible for balancing the examiners’ caseload to make sure that the examiners not only have the right caseloads but also have the right claims within that caseload. Properly done, the assignment process will allow the examiner to produce optimum results. The right balance is based on the experience of the examiner, the support level of the claims team (number…

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