ODG Reserve Calculator
The Reserve Calculator uses a proprietary statistical modeling program to help insurance claims adjusters forecast medical, indemnity, and administrative costs at the claim level. This is based on a multitude of inputs including up to five ICD9 or ICD10 diagnosis codes, procedures, and patient demographics like claimant age or state. It highlights potential “Confounding Factors” to look for and record, which can each represent a high “Risk Severity Coefficient”, defined as significant probable increases in claim costs. These factors include the presence of depression, diabetes, hypertension, obesity, opioids, smoking, substance abuse, surgery or hospital stay, and legal representation.
Indemnity, medical, and administrative costs are modeled individually and in the aggregate, allowing for adjustments in each bucket for expenses paid-to-date, existing reserves, and an “Adjustment Meter” for changes requested by adjusters based on their own expertise. High risk claims are flagged, with direction to refer for case and medical management using the evidence-based ODG guidelines. Finally, an ODG Reserve Worksheet™ is generated, to retain as documentation within the claim file.
In addition to projecting disability duration and cost based on total claim picture, the ODG Comorbidity and Reserve Calculators generate a Risk Assessment Score (RAS) on a scale of 100, which measures the relative risk level for each claim at intake and again when new information becomes available. The proprietary scoring mechanism is based on weighted component scores measuring Magnitude – the overall cost projection for a given claim cohort – and Volatility – the difference between a good and bad outcome. Where both Magnitude and Volatility are high, so too is the ODG Risk Assessment Score, and claims management entities are best served by early and active management from their most experienced staff. Alerts, triggers and interventions can be set at various levels as RAS rises.
Modeled from WLDI’s proprietary insurance claims database of approximately 2,500,000 medical claims representing about $20,000,000,000 in paid costs, ODG subscribers can access the ODG Reserve Calculator in the ODG Toolbox within the Web version of ODG. Integration and automation with existing claims systems is also available.
Watch the ODG "In the Know" video below for a brief overview of the ODG Claims Reserve Calculator (note: Risk Assessment Score not shown, as this feature was added later).