NYS Workers Compensation System Compliance Outreach: Measuring and
NYS Workers Compensation System Compliance Outreach: Measuring and Monitoring Payor Performance 2015 9/8/15 & 9/9/15 9/8/15 & 9/9/15 2 AGENDA Introductions/ Welcome Update on Proper E-claims filing Medical Received within 7 day waiting period
Scenarios How We Are Measuring Timeliness of Controversy Monitoring Compliance How We Are Measuring Percentage of Claims Controverted
Registration Process Notification of Penalty Letter Wrap-Up/ Questions 9/8/15 & 9/9/15 Proper Filing Proper e-claims filing 3 9/8/15 & 9/9/15
Proper E-Claims Filing As the Board moves forward with development of its Payor Compliance Reports and implementation of eClaims, we would like to take this opportunity to provide guidance on proper eClaims filing. A SROI PD should only be used in very limited circumstances such as when the carrier has an IME indicating no disability, a medical report indicating no disability, a different site of injury than originally reported, when an employer is paying wages and the carrier is accepting the case without liability (21-a), when claimant fails to appear for carrier scheduled appointment per 13-a(3) or scheduled IME within the 7 day waiting period, where there is a medical report in the file that indicates the claimant will be out of work for seven days or less and there is no subsequent medical report of disability beyond the waiting period, or in the rare instance where the claimant is losing time due to injuries on multiple claims and carrier is paying on one claim only, pending apportionment. One of the other below options are better in any other circumstance. Medical Only: When lost time does not exceed 7 days and the carrier does not initially dispute the occurrence of an accident or injury (causal relationship), the Carrier should file the FROI 00 Medical Only accepting liability for the medical portion of the claim whether there is medical in the file or not. Under eClaims rules, a SROI-04 may be filed after this Medical Only filing if lost time is claimed and investigation reveals a reason to deny the claim.
SROI-IP: When the employer reports a work related accident and the lost time exceeds the waiting period whether there is medical in the file or not, payment should begin (Bob was injured at work, went to the doctor from work, called to say doctor told him to come back in 3 weeks, no work until then). FROI-04 or a SROI-04 should never be filed when the only issue is whether there is medical evidence to support a claim for compensable lost time, nor should a carrier file a denial disputing Causal Relationship when the occurrence of a work-related accident/injury is not disputed. 4 9/8/15 & 9/9/15 Proper E-Claims Filing Medical Received Returning Claimant to Work Within the Waiting Period. When is Payment Due? What should be filed?
Guidelines Used: If claimant voluntarily returns to work or medical report releases claimant to work a new medical is needed. If medical report is present, follow direction of medical. Example: Medical from ER visit states out of work for 2 days follow up with Orthopedic. Medical covers 2 days a new medical is needed. To determine timely first payment, the Board will be using 18 days from the Boards received date of a medical report which takes claimant out of work beyond the waiting period. 5 9/8/15 & 9/9/15 Scenario Scenario 1: The claimant is injured on 3/9/15. Has 2 days of lost time 3/10/15 through 3/11/15 with a return to work date of 3/12/15. Claimant loses an additional day on 3/20/15. Returns to work on 3/21/15. Claimant goes back out of work 4/9/15 through 4/23/15 with a return to work date of 4/24/15. There is one medical report received for date of service 3/19/15 that states total. Please advise if there is an indemnity payment required?
Reply to Scenario 1: No. Indemnity Payment would not be due as the claimant voluntarily returned himself to work on 3/21/15 when the medical report of 3/20/15 stated he was total. A new medical would be needed stating the claimant is disabled and out of work beyond the waiting period, in order for an indemnity payment to be due. How to File for Scenario 1: The carrier would file the FROI-00 Medical only with an Initial Date of Disability as 3/10/15 and an Initial Return to Work Date as 3/12/15. Once lost time goes beyond the waiting period the carrier would file a SROI-PD with a claim type code of Indemnity; and a Partial Denial Reason (DN0294) of A, and include Denial Reason Narrative (DN0197) of Medical is present indicating claimant is out of work for 7 or less days and no further medical of disability beyond the waiting period received. Once the SROI-PD is filed, these data elements should be populated with the latest dates: Current Date Disability Began (DN0144), Current Last Day Worked (DN0145), and Latest Return To Work Status Date (DN0072). 6 9/8/15 & 9/9/15 Scenario Scenario 2: The claimant becomes injured on 8/1/15 and is out of work beginning 8/2/15. A medical note is produced on 8/2/15 excusing the employee for 3 days and releases him back to work on 8/5/15 (within the waiting period). The claimant does
not return to work on 8/5/15 as previously directed, but claimant calls to say he has another visit scheduled for 8/12/15. Based on the original note dated 8/2/15 releasing the claimant back to work within the waiting period would payment still be owed because they did not return? Reply to Scenario 2: No. Indemnity Payment would not be due as the medical note returned the claimant to work on 8/5/15, which was within the waiting period. In order for the claimant to collect indemnity benefits, he must provide a new medical stating that he is disabled and out of work beyond the waiting period. How to file for Scenario 2: The carrier would file the FROI-00 Medical only with an Initial Date of Disability of 8/2/15. Once lost time goes beyond the waiting period the carrier would file a SROI-PD with a claim type code of Indemnity and a Partial Denial Reason (DN0294) of A and include a Denial Reason Narrative (DN0197) of Medical is present indicating claimant is out of work for 7 or less days and no further medical of disability beyond the waiting period received. 7 9/8/15 & 9/9/15 Scenario Cont Scenario 2: Claimant returns to physician on 8/12/15. Medical indicates claimant is totally disabled and out of work until 9/1/15. Medical
received at the Board on 8/24/15. Would payment be due and if so, when? Reply to cont of Scenario 2 Yes, payment would be due as further medical taking the claimant out of work beyond the waiting period was received at the Board on 8/24/15. The claimant would be due indemnity for the periods of 8/2/15 to 8/5/15 and 8/12/15 to 9/1/15. Payment and SROI would be due within 18 days of the received date of the medical (8/24/15) which would be no later than 9/11/15. How to File for cont of Scenario 2: Once medical is received taking claimant out of work beyond the waiting period carrier would file the SROI-IP and make initial payment prior to 9/11/15 in order to be timely. 8 9/8/15 & 9/9/15 Scenario Scenario 3 The claimant has a back injury on 5/1/14 and loses no time from work. Claimant slips and falls on 7/1/14 injuring his left ankle and is receiving compensation for a temporary total disability. While out of work due to his ankle injury, the claimants back injury flares up and claimants doctor indicates claimant is temporarily totally disabled and out of work due to back injury. Since the claimant is receiving a temporary total rate of disability for his ankle injury, the carrier is not making payment on his back claim. How does the carrier advise the Board?
Reply to Scenario 3 In the rare instance where the claimant is losing time due to injuries on both claims and you are paying at a temporary total rate on one claim, the SROI-PD would be acceptable on the claim in which payment is not being made. How to file for Scenario 3 Carrier would file the SROI-PD with a claim type code of Indemnity and a Partial Denial Reason (DN0294) of A and include a Denial Reason Narrative (DN0197) of claimant receiving temporary total rate in file JCN #. Once a determination is made as to how payments for the lost time are to be apportioned (if at all), the carrier would then file the appropriate SROIs showing the payments for each file. Other Filing Requirements If the carrier is paying at a less than total rate on the ankle injury, then the carrier should pick up payments bringing the claimant to the temporary rate on the back claim and file the SROI-IP showing payments . Claimant is out of work for ankle injury, then has back surgery on the other file. In that case you would file a SROI-SD on the ankle claim and the SROI-IP on the back claim showing payment. 9 9/8/15 & 9/9/15 How We Are Measuring Timeliness of Controversy
10 9/8/15 & 9/9/15 11 How We Are Measuring Timeliness of Controversy Enforcement of the 18/10 Day Rule defined in NYCRR Section 300.22 : On or before the 18th day after the disability event OR within 10 days after the employer has knowledge of the disability event, whichever period is greater, the carrier, Special Fund, self-insured employer or TPA shall file electronically a Notice of Controversy(FROI-04/SROI-04) with the Board. "Disability event" means any accident, including death resulting therefrom, occurring in the course of employment or any alleged accident, including death resulting therefrom, that results in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident or alleged accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid; or any disease or alleged disease, including death resulting therefrom, claimed to have been caused by the nature of the employment and contracted therein.
9/8/15 & 9/9/15 How We Are Measuring Timeliness of Controversy The Board will begin to measure Timeliness of Controversy on only lost time claims. Due to this the timeline will be 18 days from Date of Accident, 10 days from Date Employer had Knowledge of Injury, 10 days from Initial Date of Disability, whichever period is greater. To determine Employer Knowledge Date the Board will use the earliest date of Date Employer Had Knowledge of the Injury (DN0040), Date Employer Had Knowledge of Disability (DN0281), Assembly Notice Date, Indexing Notice Date. To determine Date Claim Administrator Had Knowledge of Injury the Board will use the earliest date of Date Claim Administrator Had Knowledge of Injury (DN0041),Assembly Notice Date, Indexing Notice Date. Initial Date Disability Began/Current Date Disability Began - If Initial Date Disability Began (DN0056) and Current Date Disability Began (DN0144) are present, and the Initial Return to Work Date (DN0068) is less than or equal to 7 days then Current Date of Disability (DN0041) is used. The Board will only be measuring the filings made against the Primary Insurer of record at the time of the filing. 12
9/8/15 & 9/9/15 How We Are Measuring Timeliness of Controversy Late filing of Controversy Criteria Total number of FROI/SROI 04 filings per carrier per quarter Received date of FROI 04/SROI 04 Date of Accident (18 days) Will be taken from case folder as it is more reliable, the date of accident from the FROI doesnt have to be a perfect match with the case DN0040 - Date Employer Had Knowledge of the Injury (10 days) DN0041 - Date Claim Administrator Had Knowledge of the Injury (10 days) Assembly Date Indexing Date DN0056 - Initial Date Disability Began DN0144 - Current Date of Disability Payment without Liability prior to Controversy: DN0075 - Agreement to Compensate Code with a W without liability
DN0192 Benefit Payment Issue Date 13 9/8/15 & 9/9/15 14 How We Are Measuring Timeliness of Controversy Controversy is not timely: If the received date is after the greater of 18 days from date of accident and 10 days from employer knowledge and 10 days from Initial Date Disability began the FROI/SROI 04 is late. (25 (3)(e)) If the received date is after the greater of 18 days from date of accident and 10 days from employer knowledge date (DN0040) and 10 days from Initial Date Disability Began and 10 days after Claims Administrator Knowledge Date (DN0041). Additional penalty will be imposed. (25 (2)(a)) If any SROI is filed using Agreement to Compensate code (DN0075) with W without liability and then a SROI 04 is filed, the SROI 04 is not considered late until 1 year from
Benefit Payment Date (DN0192). If SROI 04 is filed after one year from Benefit Payment Date, although no monetary penalty will be assessed, the carrier is liable for claim. If the case is indexed, the Claim Administrator will waive (25(2)(b)) defenses when the denial is not filed within 25 days of the date of indexing. 9/8/15 & 9/9/15 Monitoring Compliance Timeliness of Controversy 15 9/8/15 & 9/9/15 16 Monitoring Compliance The Board expects to use penalties as the last step of the process. Payors will have sufficient time to work with the Board to understand where they are out of compliance and the steps that can be taken to avoid penalties. Penalties for Untimely Controversy
WCL 25 (3)(e) If the carrier or employer fails to file a notice within 18 days of disability or 10 days after employer knowledge, the Board may impose a $50 penalty. WCL 25 (2)(a) When a carrier fails to file a notice of controversy or begin payment within the prescribed period or within 10 days of claims administrator knowledge (whichever period is greater), the Board may, after hearing, impose a $300 penalty in addition to any other penalty. 9/8/15 & 9/9/15 17 Monitoring Compliance Performance Standards: WCL 25 (3)(e) If the carrier or employer fails to file a notice or report requested or required by the Board or otherwise required within the specified time period or within 10 days if no time period is specified, the Board may impose a $50 penalty. The Board is implementing the following performance standards: The penalty under 25(3)(e) will not be imposed as long as a carrier meets the below performance standards per category. Your filings will be measured for each
category, per quarter, against the performance standard. If the performance standard is met in that category your 25(3)(e) penalty will be waived. Timely First Report of Injury - 70% increasing 5% each quarter Timely First Payment - 70% increasing 5% each quarter Timely Filing of Notice of Controversy 70% increasing 5% each quarter Performance Standard will max out at 85% for all three categories. Once goals reach 85%, they will be reviewed periodically for possible adjustments. 9/8/15 & 9/9/15 How We Are Measuring Percentage of Claims Converted 18 9/8/15 & 9/9/15 19 How We Are Measuring Percentage of Claims Controverted
Payors will not be evaluated and penalized based on their rates of controversy. This score is included solely as a measure of relative system performance and as a possible indicator of areas that may need additional examination. In the near future, success rates in controversy will be included with this measurement. Number of total filings Each case should be counted only once per carrier in any one quarter Total number of Initial FROI with lost time Number of FROI/SROI 04 with lost time Number of SROIs with agreement to compensate code (DN0075) with a W without liability Number of SROI 04 filed after a SROI with agreement to compensate code (DN0075) with a W without liability. 9/8/15 & 9/9/15 17
How We Are Measuring Percentage of Claims Controverted Formula to Determine Percentage of Controversy Take the total number of Initial FROI w/ lost time filings Take the total number of FROI/SROI 04 add to the total number of SROI 04 filed after SROI with Agreement to Compensate Code DN0075 with W without liability Divide these two numbers to get percentage Percentage of Controverted Claims (Example) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total # of initial FROI with lost time
30 40 35 45 # of FROI/SROI 04 with lost time 5 8 7 9 # of Cases accepted w/o
9/8/15 & 9/9/15 Registration Process 21 9/8/15 & 9/9/15 Registration Process All Carriers, Self-Insureds and Municipalities would need E-claims Inquiry access. In order to get E-claims Inquiry access please register on line at http://www.wcb.ny.gov/content/ebiz/eclaims/Registration/howtoregInquiry.jsp Payor Compliance Agreement will need to be signed in order to review Payor Compliance Reports. Payor Compliance Agreement will be an electronic document A Payor Compliance Agreement will be signed for access per W-code (may list multiple W-Codes on one agreement) Please send name and e-mail address of executive officer for each W-code to [email protected] in order to receive Payor Compliance Agreement for signature Once the Payor Compliance agreement is signed and approved by the Board, anyone with e-claims Inquiry Access for that W-code (carrier or TPA) would then be able to see the Payor Compliance
Reports. 22 9/8/15 & 9/9/15 Notification of Penalty Letter 23 9/8/15 & 9/9/15 Penalty Letter Notification As of January 2016, the NYS Workers Compensation Board will begin to issue penalties against Insurance Carriers, Self-Insured Employers and Municipalities for not filing a timely first report of injury (FROI) in the fourth quarter of 2015. Thereafter, additional measurements will be implemented along with additional penalty letters being sent. In order to expedite the process, the Board is requesting that each carrier (W code) send the carrier name, W code, full address along with the contact persons name and e-mail address in which the penalty letter(s) should be sent. Please forward this information by e-mail to: [email protected]
with penalty letter in the subject line. Please note that the address submitted will ONLY be used by the Board for the submission of the Payor Compliance penalty letters and will not affect any other mailings the Board currently sends. Please be advised that we will not send penalty notices to a Third Party Administrator or a Third Party Administrators address. 24 25 9/8/15 & 9/9/15 Wrap Up/Questions Share your thoughts, questions and feedback with: Denise Hughes, Monitoring Program Manager Email: [email protected] Visit our website: http://www.wcb.ny.gov/content/main/Monitoring/Overview.jsp
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