Situation

• California had the highest workers' compensation premiums for employers in the United States. A major reason: the time and cost to resolve disputed medical claims for injured workers.
• Under the state's complex judicial process, decisions on claims could take months.
• Too often, the result was undesirable health outcomes, such as the inappropriate dispensing of opioids.

Challenge

Close gaps in program efficiency by creating a more streamlined, cost-effective, and reliable method of claims resolution.

Solution

As part of California's efforts to control employers' workers' comp premiums, we transformed the state's program by implementing an Independent Medical Review (IMR) process.

Instead of having opposing medical experts present testimony to non-clinical judges, our process utilizes independent healthcare professionals to resolve disputes about the necessity of treatment.

Screened to avoid any conflicts of interest, these expert reviewers - including doctors, nurses, and other clinicians - provide efficient, objective recommendations, expediting the appeals process and greatly reducing costs.

How we did it

The Maximus^® IMR solution showcases our digital transformation capabilities, including the use of data analytics, robotic process automation, and machine learning to streamline processes using business rules. These rules guide the reviewers, ensuring decisions are based on the best peer-reviewed and epidemiological evidence.

Scale has been essential in meeting California's needs. We've handled case numbers that have far exceeded initial estimates and our IMR document collection portal has processed more than one million pieces of information.

By rethinking processes from top to bottom, we've enabled the state to close a significant budget gap and achieve better outcomes, too.

Results

$1 billion
in annual savings (total medical costs declined by $2.5 billion or 6 percentage points over the last five years)

10 days vs. 231 days
to resolve claims

33% decrease
in medical service transactions leading to a 21% decrease in medical costs

85% decrease
in prescription transactions per claim (opioid costs now account for only 8% of all prescription spend)

42% decrease
in advisory pure premium rates