Running Head: Case Study 1: Athens Medical Claims Reengineering

Case Study 1: Athens Medical Claims Reengineering

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Running Head: Case Study 1: Athens Medical Claims Reengineering

Introduction

Everyone requires treatment whenever they get sick, and it can become expensive.

Having employers pay for the treatment usually is the cheapest way for people to get treatment.

There are however instances where the employees could exploit the employer by making them

pay more than they need. Understanding these situations can be important in ensuring employees

get the medical assistance they need while protecting the organization as well.

Descriptive and Prescriptive Statements

A descriptive statement is one that that states how things are currently. It provides

information on the present situation by stating the facts behind it. A descriptive statement within

this case study is "September 22, 2008, Workers' Compensation Insurance Rating Bureau

(WCIRB) of California report demonstrate a 57.7% decline in indemnity claim frequency over

the past six years." (Jenkins, 2009). The statement is one that supports factor that directly

influences the California workers' compensation industry. A descriptive statement needs to be

based on fact, and the above statement qualifies in that regard.

So while a descriptive statement will state how things are, a prescriptive statement will

say how things should be. It is put forward as either a way things should get done in future or the

results of them. Under this case study, a prescriptive statement is like the following, "With an

active employee's claims, the best strategy may be to keep the claim open and monitor it closely.

If the employee discontinues treatment, the claim administrator can issue an administrative

closure, a strategy that takes time to execute, but may be very effective." (Jenkins, 2009). The

above statement is descriptive because it offers a solution to employers on a best practice for

settling future medical claims and show how the program could become.
Running Head: Case Study 1: Athens Medical Claims Reengineering

Goals for this Case Study

The goals of this case study are meant to present a viewpoint at the end that was either

not clear or known. These goals for the case are as follows.

Explain the history behind future medical claims – while they represent a considerable

part of a lot of organizations' claims, future medical claims remain under the radar as far as

attention goes. The lack of knowledge and information on these claims has therefore led to a

situation where the organization is seeing a strain on their finances. (Jenkins, 2009). By

exploring the history of these claims, the case study will provide insights into why they are

common. It could eventually lead to organizations finding sustainable ways of managing and

finally getting rid of unnecessary financial burdens placed on them by individuals who aren't

even working for them.

Explore the impact of future medical claims on organizations – since most of them are

resolved and are by nature less dynamic compared to active indemnity claims, organizations

might not have a full picture of the effect of the claims. Some of the claims could have the

organization be responsible for them for the entire life of the claimant. Some organizations have

become used to them that they just do not bother examining and considering the impact of the

claims. (Jenkins, 2009). The case study collects information from across the industry and

provides a much more unobstructed view of the claims on individual organizations and across

the board.

Provide best practice solutions – with the problem, and its impact identified, the next step

would be to come up with solutions. The case study runs through some solutions that could fix

the situation in different ways. (Jenkins, 2009). These solutions provide new ways that
Running Head: Case Study 1: Athens Medical Claims Reengineering

organizations can approach the issue future medical claims in a manner that will not leave them

bearing financial commitments they shouldn't be born.

Obstacles for this Case Study

The case study is confronting a serious issue and is therefore bound to experience some

obstacles. Some of these include the following.

Prohibitive medical costs – it is currently costly to get medical treatment without medical

insurance. Individuals that embark on treatment without insurance will end up spending so much

they could end up bankrupt. Future medical claims provide a cover for such an eventuality,

especially for complications resulting from the subject of the future medical claims. Since

organizations will cover most future medical claims for life, the individual is provided with a

lifetime of medical care paid for by someone else. (Jenkins, 2009). People are therefore more

likely to go after future medical claims.

Dependence on prescriptive drugs – while one-off drug purchases can be manageable for

most people, those with long-term injuries have to keep taking the drugs for longer. Footing the

financial commitment for these drugs over an extended period will, therefore, become untenable

for them. By leaving a future medical claim open, the individual will get to have the drugs paid

for under the claims and get spared from catering to the bills themselves. (Jenkins, 2009). People

would be unwilling to let go of the claims.

Increased employee retention – as employees remain at organizations for longer, the

organization might prefer to keep the future medical claims for active employees rather than

provide them with lump-sum payments. It is because a re-injury could occur in future and the
Running Head: Case Study 1: Athens Medical Claims Reengineering

organization will have to repay the lump sum again. (Jenkins, 2009). In such a case, maintaining

a future medical claim will be cheaper in comparison.

Alternative Obstacle Resolutions for the Case Study

The above obstacles will place a strain on the organization. Ways to resolve them

include the following.

Providing the employee with medical insurance – it will ensure that the cost of claims is

contained within a more formal solution that can offer the organization a better way of managing

the medical costs of its employees. (Verma, Taneja, & Arora, 2017, August).

Insisting on a lump sum for departing employees – instead of catering for an employee's

medical costs under the future medical claims, an organization could instead draw contracts that

remove liability for future medical claims once an employee leaves the organization.

Amending Medicare – the amendments will reduce the burden of future medical claims

from employers, and they could share it with Medicare, which currently does not bear such costs

for the individual. (Shi, Sun, Li, Cui, Yu, & Miao, 2016, February).

Normal and Abnormal Scenarios

The normal scenarios will be as follows.

 The employer should bear the medical treatment costs for its employees.

 Individuals will be more likely to seek cheaper ways of covering their medical

costs.

 Organizations will seek ways of reducing any costs it does not deem necessary to

its operations.
Running Head: Case Study 1: Athens Medical Claims Reengineering

 Individuals with disabilities should have access to employment opportunities.

 Long-term medical costs cannot be adequately covered by lump sum payments.

Abnormal scenarios will be as follows.

 The government is not playing a bigger role in covering individuals with

disabilities.

 A large number of future medical claims will impact employment environment

adversely as employers bear more costs.

 Long-term maintenance of future medical claims will strain organizations and

negatively affect their bottom line.

 Individuals with pre-existing injuries are less likely to secure employment so

organizations can avoid future medical claims.

 Changing workforce demographics will increase the occurrence of future medical

claims rather than reduce them.

Requirements that might need to get prioritized

With limited resources, the focus should be on the following requirements.

Regular communication between the injured employee and their employer will ensure

that the employer can put in place measures to avoid injuries in the workplace.

Medical claims should be honored only for those individuals that remain employees of

the organization.

Maintaining proper documentation can lead to fewer confusions and ambiguity, and the

employer ends up paying less than they might have otherwise paid.
Running Head: Case Study 1: Athens Medical Claims Reengineering

Conducting more comprehensive investigations can reduce the number of cases that need

attention by doing away with non-qualifying cases.

The employer should help the employee return to work faster after treatment so that they

can gain more value for the money spent on the treatment.
Running Head: Case Study 1: Athens Medical Claims Reengineering

References
Jenkins, J. R. (2009). A Claim on the Rise: Future Medical. Retrieved from

http://www.athensadmin.com/pdf/Athens-FutureMedical.pdf.

Shi, Y., Sun, C., Li, Q., Cui, L., Yu, H., & Miao, C. (2016, February). A Fraud Resilient Medical

Insurance Claim System. In AAAI (pp. 4393-4394).

Verma, A., Taneja, A., & Arora, A. (2017, August). Fraud detection and frequent pattern

matching in insurance claims using data mining techniques. In 2017 Tenth International

Conference on Contemporary Computing (IC3) (pp. 1-7). IEEE.