Presentation on theme: "FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief"— Presentation transcript:
1FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief Florida Division Of Workers’ Compensation Employee Assistance and Ombudsman OfficeFWCI Annual Conference August 24, 2005Roy O. WoodBureau Chief
2Employee Assistance and Ombudsman Office Effectuate the “self-executing” features of the workers’ compensation system without undue expense, costly litigation or delay in the provision of benefits.
3Core Functions of EAO Outreach and Education Call Center/Request for AssistanceEarly Intervention ProgramOmbudsmanInvestigations
4Outreach Heighten awareness Add value through contact Benefits to all stakeholders
6Call Center/Request for Assistance Centralized Access PointDedicated telephone and web-based centerStaffed by professionals who will beable to answer questions for allstakeholders
7Division of Workers’ Compensation research suggests that in the past 15 years over 60% of benefit costs were incurred by 10% of claimsIt is well known that a small minority of the claims produce the highest costs to the system.We are in the process now of identifying those lost time claims, though Division data.
8Early Intervention Program Identification of potentially high exposure claims through the use of technologyProactively contact injured worker to maximize return to work
9Ombudsman Advocate to foster communication between employer, adjuster andinjured workersWill explain benefits to injured workersWill reduce load on adjuster
10InvestigationsIn the case of an impasse, or unclear facts, a case may be referred to an investigatorObjective pursuit of the factsExercise authority provided under (9) F.S.Facilitate dispute resolutionIn the event an impasse is reached, or the facts or unclear, a case may be referred to an investigator.It will be the investigators role to “objectively pursue the facts and focus on the substantive issues preventing resolution of the case.Section (9) gives the Division the authority to investigate, cause medical examinations, hold hearings and take any other action it considers necessary to protect the rights of the parties. Section (2)(a) provides that EAO may compel the parties to attend conferences to resolve issues quickly and in the most efficient manner possible.
11EAOEAO vision facilitating the self-execution of the WC lawLegislatively mandated to assist the injured workerEAO must wear several hats
12EAOEAO strives to be a professional front-line participant in the WC system adding value through its involvement
14Workers’ Compensation Claims 69L-3, F.A.C. Fred BecknellInsurance AdministratorBureau of Monitoring & Audit
15Workers’ Compensation Claims 69L-3, F.A.C. 226 days have passed since the Rule became effective on January 10th.136 days have passed since the Forms became mandatory on April 10th.
16A few observations in regard to the timely filing and accuracy of Workers’ Compensation claim forms. DWC-1 / First Report of Injury or IllnessDWC-4 / Notice of Action/ChangeDWC-12 / Notice of DenialDWC-13 / Claim Cost Report
17Required Fields / All Forms Employee’s name (First, middle, last)Employee’s social security number *Month, day and year of the accident(mm-dd-yy or mm-dd-ccyy)Sent to Division Date* Or Division Assigned Number (DAN)
18Reporting of the Social Security Number 69L-3.003(3)(a) Report the actual Social Security Number as assigned by the Social Security Administration.If unknown or the employee does not have one, the claims-handling entity shall contact the Division by means of the Division’s website:Follow the directions (under Records Management - Division Assigned Numbers).
19Required Fields on all Forms 69L-3.003(3) Insurer Code # & Insurer NameService Co/TPA Code # *Claims-handling Entity File #Claims-handling Entity’s Name, Address & Telephone* If applicable
23Type in the company name and hit the “Submit Query” key. InsuranceType in the company name and hit the “Submit Query” key.
24The Company Name, Insurer ID # & Corresponding Information is Displayed.
25Filing of WC Forms L-3.003(5)All submissions of forms filed with the Division shall conform with the promulgated form in design, layout, field size and content (data elements).
26DFS-F2-DWC-1 / 69L-3.0045 First Report of Injury or Illness Major changes for discussionReporting of the Claims-handling Entity InformationReporting of Indemnity Only Denied CasesReporting of Delayed Disability CasesReporting of Lost Time CasesReporting of Penalties & Interest Paid to the Employee
27Claims-Handling Entity Information 69L-3.0045(1)(d)
28“Indemnity Only Denied Cases” 69L-3.0045 (1)(d)5.b and (2)(g) Report cases where only the indemnity benefits are denied (medical benefits being provided).Box 1(b) “Indemnity Only Denied Case” is to be marked. Forms DWC-1 and DWC-12 are to be filed with the Division at the same time.
29Reporting of Delayed Disability Cases 69L-3.0045(2)(b) When disability is not immediate and continuous but result in 8 or more days of disability - send a completed DWC-1 within 6 days after knowledge of the 8th day of disability.
30Delayed Disability Case 69L-3.0045(1)(d) 5. c. i.
31Reporting vs. Paying Delayed Disability Cases Important Reminder: Do not confuse the filing of the DWC-1 with the timely payment of indemnity benefits pursuant to s (2)(a), F.S.Payment is due on the 6th day after the 8th day of disability.Filing is due within 6 days after the knowledge of the 8th day of disability.
32Reporting of Lost Time Cases 69L-3.0045(2)(a) When disability is immediate and continuous for 8 or more days, send a completed DWC-1 within 14 days after knowledge of the injury or illness.
33Reporting of Lost Time Cases 69L-3.0045(2)(a) Initial lost time casesFull salary cases (employer paid for 8 or more days)Death cases with/without dependentsVolunteers
34Lost Time Case – Required Fields 69L-3.0045(1)(d) 5.d.
35Reporting of Lost Time Cases If the initial payment of indemnity benefits is for TP, IB or results from an agreement or order for indemnity benefits send the completed DWC-1 within 14 days after the date payment mailed.69L (2)(c) – TP Benefits L (2)(d) – IBs L (2)(e) - Settlements
36Reporting of Penalties & Interest 69L-3.0045(1)(f)
37DWC-4 Notice of Action/Change 69L-3.0091 File with the Division within 14 days of the knowledge of the action or change which is being reporting for lost time cases.Copies of the Form are to be mailed to the employee and employer at the same time.
38Incomplete DWC-4s LThe filing of the form with only the “Remarks Section” completed will not constitute filing of the required information - applicable field(s) are left blank.
39Suspensions of Benefits 69L-3.0091(2) State the “Effective Date” (the last date through which benefits were paid) of the suspension and the applicable suspension “Reason Code”.
4069L (3) ReinstatementsUpon the reinstatement of indemnity benefits after a suspension, report the effective date of the “Indemnity Reinstated After Suspension” & the “Disability Type” of benefits being reinstated.
4169L-3.0091(4) Return To Work Report when the employee has been medically released to RTW,the assignment of physical restrictions,the removal of all physical restrictions,the actual RTW.
4269L (5) SettlementsReport the “Date Payment Mailed” resulting from a final order of indemnity benefits pursuant to s (11), F.S.* This date can not be reported as earlier than the date the settlement was actually approved.
43DWC-12 Notice of Denial 69L-3.012(1) Copies of the DWC-12 are to be mailed to the employee, employer and any additional party requesting payment or authorization, within 14 days of the date the decision to deny or rescind the denial.
44Denial of Compensability 69L-3.012(2) When denying the compensability of or coverage for a case, send the DWC-12 to the Division within 14 days after notification of the injury, illness or death with a completed DWC-1.
45Denial of Indemnity Only 69L-3.012(3) When denying only the indemnity benefits of a claim send the DWC-12 to the Division within 14 days after notification of the injury, illness or death with a completed DWC-1.
46Denial of Subsequent Indemnity 69L-3.012(4) When denying any subsequent indemnity benefit on a lost time case send Form DWC-12 within 14 days of the knowledge of the requested benefit being denied.
47Petition for Benefits 69L-3.012(5) If a Petition for Benefits (PFB) is the first notification of an injury and you are denying the case in its entirety (or only the indemnity portion), send Forms DWC-12 and DWC-1 to the Division within 14 days of the receipt of the PFB.
48Rescinded Denial L-3.012(6)When rescinding the denial of previously denied indemnity benefits send Form DWC-12 with the “Denial Rescinded Section” completed within 14 days of the date that the denial was rescinded.
49DWC-13 Claims Cost Report 69L-3.016 Initial Report – file within 30 days after the 6th month anniversary of the date of accident – no early filings accepted – unless filing as the final report.Annual Reports – file within 30 days after the annual anniversary of the date of accident – no early filings accepted – unless filing as the final report.
50Workers’ Compensation Claim Forms 69L-3.025(3) All forms filed on or after April 10th, 2005 must be the 08/2004 version (regardless of the date of injury).
51Coming Spring ‘06 Update of 69L-3 / DWC-1 Optional reporting of the SIC Code until October 2006 in lieu of the NAICS Code.Required reporting of the employer’s knowledge of the injury or illness.Required reporting of the NAICS (SIC) Code and the NCCI Code on the DWC-1.
52Coming Spring ‘06 Update of 69L-3 / DWC-13 The reporting of previous paid indemnity and medical for acquired claims can be reported in an “Acquired” or “Unallocated” format. All reporting will include the claim cost amounts for each applicable indemnity and medical in addition to the acquired amounts.
53Great way to keep current with updates from the Division. DWC-e-Alert ProgramGreat way to keep current with updates from the Division.Sign up for the DWC e-Alert program for the quickest notification of rule making & other DWC activities. Located on the Division’s Website.
55Division of Workers’ Compensation Office of Data Quality & Collection Don DavisSenior Manager Analyst SupervisorData Quality & Collection(850)How to Avoid Form Rejection and Penalty Exposure
56Data Quality – Procedures for Filing Documents W.C. Claims Rule 69L (1) effective January 10, 2005The Division shall return to the claims-handling entity any document on which the appropriate information required in subsection (3) of this section and paragraph 69L (1)(d) F.A.C. does not appear, and will notify the claims-handling entity of its error or omission.The document will be considered completed and in compliance when the corrected document is resent to the Division.
57Indemnity Claim Forms Document Returned by Division (DWC-1, DWC-4, DWC-12, DWC-13)Effective April 11, 2005, the Division began enforcing the submission of required data fields for DWC forms pursuant to the WC Claims Rule, 69L-3.003(1), F.A.C.Example for Paper Filed FormsDocument Returned by DivisionDue to Non-compliance with Rule 69L-3.003Reviewer: ______________ Date: ____________
58Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1) #1#1 – “Sent to Division Date” is Missing
59Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1) #2 – Claims Handling Information is Incomplete#2
60Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1) #3 – Injury/Illness that Occurred is Missing#3
61Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1) #4#4 – Insurer Name and/or Insurer Code Number are Missing
62Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13) #1#1 – Weeks/days missing for indemnity when $ amount is given
63Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13) #2 – Insurer Name and/or Insurer Code Number are Missing#2
64Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13) #3#3 – Settlement Dates are Missing
65Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13) #4#4 – AWW / Comp Rate Missing
66Question – What percentage of all returned DWC-1’s and DWC-13’s are rejected for these preceding “top 4” data fields?25 – 49%50 – 75%76 – 100%Answer : B – 75%
67Legislative Mandate to Review All Medical Bills (DWC-9, 10, 11, 90) Section 440.20(2)(b), F.S. The division is now required to review 100 percent of all submitted medical bills to evaluate insurer performance.Last fiscal year, over four million medical bills were electronically reviewed in order to assess timely insurer performance standards pursuant to s (6)(b), F.S.
68Requirements for Medical Bill Completion and Filing (DWC-9, 10, 11, 90)Florida Workers’ Compensation Medical Services, Billing, Filing and Reporting Rule (69L F.A.C.)Effective Date: July 4, 2004Projected Amended Effective Date:Mid-September 2005
69Important Highlights for Insurer Responsibilities Medical claim bills are required to be filed with the Division for “ALL MEDICAL ONLY AND LOST TIME CASES”.Insurer must pay, adjust and pay, disallow or deny bill within 45 calendar days from date received [s (2)(b)]
70Important Highlights for Insurer Responsibilities Insurer must correct and re-file all rejected medical bills within the 45-day filing timeline.Once the medical bill records are uploaded to our system, an electronic confirmation report is immediately issued to the EDI submitter that details the acceptance or rejection of each record submitted.
71CAUTION!Rejected Medical Bills (DWC-9, 10, 11 & 90) can lead to penalties if not properly corrected and timely resubmitted to the division.
72Top 4 Data Elements Causing Rejection of DWC-9 #1#1 – Federal Employer Identification Number (FEIN) provided by the EDI Submitter does not match Division Records#2 – EOBR Codes used incorrectly#2EDI Medical Record Layout
73Top 4 Data Elements Causing Rejection of DWC-9 EDI Medical Record Layout#3#3 – Blank or Zero Values submitted in the EDI Record Layout#4 – No Matching Code Value from AMA CPT or ICD Manuals#4
75Rejected Medical Bills For calendar year 2003, over 43,000 medical bills were rejected by the division for quality issues, and never corrected and resubmitted.For calendar year 2004, over 31,000 medical bills were rejected by the division for quality issues, and never corrected and resubmitted.
76Rejected Medical Bills For the first six months of calendar year 2005, only 2,294 medical bills were rejected by the division for quality issues, and not corrected and resubmitted to the division.
77Division Steps to Help Insurers File Accurately and Timely Contacted all 101 EDI medical submitters individually to validate and/or correct their insurer and FEIN numbers.Created an educational/training guide (with the assistance of AHCA) on the proper usage of EOBR codes, and sent it to all Medical EDI submitters. The guide is also posted on DWC’s website, under the “EDI” link.
78HELP from the Medical EDI System Same day notification to Insurers of the “Claim Processing Report” listing accepted/rejected medical bills. Rejected data fields are noted in red for quick and easy identification – real time accessPotential “duplicate” medical bills are identified in the new system (MDS), and flagged for correction on the “Claims Processing Report” – real time access
79HELP from the Medical EDI System Developed a cumulative “Outstanding Rejected Medical Claims” report which is ed to submitters twice a month. This feedback helps our customers manage rejected medical claims.Created an Internet Website for direct online entry, validation, submission, correction, and resubmission of medical data. This website went live in January 2005 – real time access.
80HELP from the Claims EDI System An Acknowledgement report listing detailed errors is returned to Claim Administrators for every Claims EDI submission.Claim Administrators notified if no DWC-1 on file, for an electronically filed DWC-13.
81HELP from the Claims EDI System “Report cards” are issued monthly to Claim Administrators, which include the top 5 recurring errors.A cumulative monthly report of Rejected But Not Resubmitted DWC-1’s and DWC-13’s is also provided.
82Suspense of Paper Filed Claim Forms when Required Data is Missing Original “Sent to Division Date”: /15/05Form received at Division (DWC): /20/05DWC rejection stamp date: /21/05(date form is returned to sender)Date completed form must be resent to DWC: 07/05/05(06/21/ days)New “Sent to Division” date: /30/05Data completed Form received at DWC: /06/05Original “Sent to Division” date honored by DWC: 06/15/05
83Recommendation to Reduce Paper Filed Claim Forms Distribute the information for top reasons for rejection to the appropriate personnel responsible for completing the forms. Conduct training if necessary.
84Recommendations to Reduce Medical Bill Violations Submit data to the division daily if possible, or at a minimum of once per week.Require your medical bill review vendor to copy you on the bi-monthly “Outstanding Rejected Medical Claims” report. Use the Centralized Performance System (CPS) to “monitor” your medical bill rejections.
85Recommendations to Reduce Medical Bill Violations Encourage your medical bill vendor to build “in-house” edits that match the division’s edits and requirements, and have the vendor edit your medical filings prior to submission to the division.Contact the Office of Data Quality and Collection for a customized report that identifies the top reasons your medical bills are rejecting.
87Division of Workers’ Compensation. Update on. Proof Of. Coverage. and Division of Workers’ Compensation Update on Proof Of Coverage and Claims EDILinda Yon, EDI Coordinator Phone:
88A copy is available on DWC’s website at www.fldfs.com/wc/ Rule Chapter 69L-56 Florida Administrative Code is the EDI Rule for Proof of Coverage and Claims (non-medical)A copy is available on DWC’s website at
90Overview of changes to 69L-56 effective 5-29-05 Revised all EDI Trading Partner FormsFor Proof of Coverage - adopted the IAIABC Release 2 Proof of Coverage Implementation Guide, and a revised FL POC EDI Implementation Manual
91Overview of changes to 69L-56 effective 5-29-05 Transferred Proof of Coverage cancellation/non-renewal requirements and filing requirements from 69L and 69L to 69L-56.
92Overview of changes to 69L-56 effective 5-29-05 As of June 1, 2005, EDI transactions must be sent as follows:POC EDI: via Secure Socket Layer/File Transfer Protocol (SSL/FTP)Claims EDI: via SSL/FTP or the Advantis Value Added Network (VAN).
93Overview of changes to 69L-56 effective 5-29-05 An insurer may contract with a third party vendor, or use a third party vendor’s software for electronically sending transactions to the Division, but the insurer will still remain responsible for the timely filing of EDI transactions.
94Overview of changes to 69L-56 The “Electronic Supplement to the First Report Of Injury” (8th Day of Disability) requirement was effectiveIt will remain in place, through the date the insurer begins submitting via EDI in the new IAIABC Release 3 format.
95Overview of changes to 69L-56 After the insurer is submitting data in the R3 format, the Supplement to the First Report format will no longer be required.
96Future EDI Claims Filing Requirement for ALL Insurers
97Claims EDI Filing Requirement The requirement to implement Claims EDI will begin with the electronic form equivalent of:First Report of Injury or Illness (DWC-1)Claim Cost Report (DWC-13)
98Proposed EDI Claims Implementation Requirement: The Division will divide insurers/self-insurers into three implementation groups, based on insurer code number.Lowest one third in the series, and current Release 1 Trading Partners will implement first.Middle one third in the series will implement next.Highest one third in the series will implement last.
99Sample Claims EDI Implementation Schedule The first group is to begin testing 9 months after the effective date of the rule, and must be in production no later than 1 quarter after the testing period begins.Example: If Effective Date of Rule:First Group Must Begin Testing:First Group Must Be In Production:
100Proposed Claims EDI Implementation Schedule The second group is to begin testing no later than 12 months after the effective date of the rule, and must be in production no later than one quarter after the testing period begins.
101Proposed Claims EDI Implementation Schedule The third group is to begin testing no later than 15 months after the effective date of the rule, and must be in production no later than one quarter after the testing period begins.
102When the R3 rules become effective and it is the Insurer’s scheduled time to begin submitting DWC-1’s and 13’s via EDI: An Insurer must submit EDI transactions to the Division using the national IAIABC Claims EDI Release 3 format.
103The Release 3 Claims Implementation Guide can be downloaded from the IAIABC’s website. This guide contains the transaction record layouts, data dictionary, scenarios, trading partner requirements, etc.
107Florida’s POC EDI Implementation Manual is available under the EDI link on the Division’s website. It provides all the FL specific requirements, including required fields, edits and error messages.EDI
111The FL Claims EDI Implementation Manual will be revised to match the requirements of Release 3 prior to the filing of the Rule 69L-56 amendments requiring the electronic reporting of EDI First/Sub Reports.
114How To Prepare For EDI Claims Release 3 Download (at no charge) the EDI Claims R3 Implementation Guide fromBecome familiar with the flat file formats, data elements, etc.
115How To Prepare For EDI Claims Release 3 Determine what fields you may have to change or add in your system to meet the EDI R3 requirements.(Ex: EE name must be sent as separate fields-First, Middle, Last, Suffix)
116How To Prepare For EDI Claims Release 3 Determine if you will do the programming “in house” or use a claims system or vendor that is prepared to handle the R3 format and specifications.Consider attending Release 3 training provided by the IAIABC EDI Leadership Team. Linda Yon will be one of the instructors.
117How To Prepare For EDI Claims Release 3 Analyze the quality of your data. If you receive a large volume of phone calls/letters from the Division regarding deficiencies of the data on your paper forms (ex: DWC-13), carefully analyze any trends in the deficiencies and correct them prior to EDI.
118Examples of Data Deficiencies on DWC-13’s: DWC-13 filed, but no DWC-1 previously filed.IB Benefits paid, but no prior DWC-4 filed reporting MMI Date or PI rating.
119Examples of Data Deficiencies on DWC-13’s: Indemnity or Medical benefits previously reported on DWC-13 are not reported on current DWC-13.Indemnity or Medical benefits reported on current DWC-13 are less than previously reported on prior DWC-13.
120EDI is intended to be a computer-to-computer exchange of information and less likely to have errors; HOWEVER, it is essential that claim administrators edit the data as it is input in to their database, and before it is sent to the Division.
121All EDI programs at the Division have standard edits that are applied to ensure data quality, and those edits are provided to all claim administrators in the Florida EDI Implementation Manuals.
122The Division will acknowledge every EDI transaction, on the standard EDI Acknowledgement (AKC) format.This report tells the Claim Administrator how many records passed edits (TA), how many failed edits (TR), and the errors that caused the record to reject.ACK Report
123(for existing EDI Trading Partners) The EDI Team is proud to announce its new online web based Claims EDI Data Warehouse(for existing EDI Trading Partners)
124This web database will allow claim administrators in any field office to have access to review the Claims EDI transactions they have submitted, and any fields that were in error.EDI
125Claim Administrators will be able to view the actual data submitted on any EDI transaction, which may appear different than what is seen on the claim administrator’s internal system.
126This database will assist the claim administrators in resolving EDI errors faster, and may also assist in resolving CPS data issues.Claims EDI Warehouse
133Claim Administrators will also have instant access to Florida specific (proprietary) performance reports produced by the EDI Team, and must access this database to receive those reports.Proprietary Acknowledgement ReportsMonthly Rejected/Not Resubmitted ReportMonthly Report CardNote: These Florida Performance Reports will no longer be sent via FTP. Claim Administrators must now access them via this database.
135IAIABC Claims EDI Comprehensive Release 3 Training In Florida
136IAIABC Claims EDI Comprehensive Release 3 Training In Florida This 3 day training will be given by the national Co-Chairs of the IAIABC EDI Committees and will provide a detailed overview of the Claims EDI R3 Implementation Guide
137IAIABC Claims EDI Comprehensive Release 3 Training In Florida November 29th - December 1stSarasota – HyattSpace limited to first 150 to submit registration with payment
138IAIABC Claims EDI Comprehensive Release 3 Training In Florida This training will provide critical instruction for both a “business” person and a “technical/systems” person from within a company.To register see the information on the IAIABC website under the “EDI” link.
139EDI Contacts at DWC Linda Yon Karen Kubie Tonya Granger EDI CoordinatorKaren KubieClaims EDITonya GrangerPOC EDI
142What is the Centralized Performance System? A web based, real time interface between insurers/self insurers and the Division of Workers’ CompensationAllows the Division and insurers/self insurers to monitor payment and filing performanceTwo modules – Medical and Indemnity
143CPS Medical Module Review of medical billing payment and filing performance by insurer in accordancewith standards set forth in Florida Statutes,Chapter 440.
144CPS Medical Module Activated in November 2004 Insurers were integrated into CPS as all medical data was reported electronically.Two key components are:- Payment performance evaluation- Filing performance evaluation
145CPS Medical Module Payment performance component Medical bills must be paid, disallowed, or denied within 45 days of the insurer’s receipt of the bill.Performance is measured by a statutory performance standard of 95% timely payment of bills.
146CPS Medical ModuleFailure to maintain a performance standard of 95% timely payment results in the following:$25.00 per bill for each bill below the 95% timely performance standard, but meeting a 90% timely performance standard.$50.00 per bill for each bill below the 90% timely performance standard.
147CPS Medical Module Violations are calculated monthly Performance standard is applied to all bills of each individual form type DWC9, DWC10, DWC11, and DWC90
148CPS Medical Module Filing performance component Medical bills must be filed with the Division within 45 days of the final disposition of the bill.Failure to meet the 45 days filing performance results in violations.
149Rejected not Resubmitted Medical Bills Bills that have been submitted to the Division butwere rejected for failure to pass system edits.When the bill is resubmitted properly, it isprocessed through CPS.Failure to resubmit the bill within 90 days of therejection date results in a filing violation.
150CPS Indemnity Module Review of the DWC-1 (Notice of Injury) initial payment of compensation andfiling performance as set forth inChapter 440, Florida Statutes.
151CPS Indemnity Module Activated in June 2005 Analyzes all DWC-1 forms submitted to theDivision in a calendar monthEvaluates information for two components:- Timely payment of initial compensation- Timely filing of the DWC-1 with the Division
152CPS Indemnity Module The Division monitors the timeliness of the initial compensation payment toinsure injured workers are promptlycompensated as required by law.Failure to provide benefits timely resultsin the following…
153CPS Indemnity ModuleViolations for the Late Payment of Compensation in accordance with Section , Florida Statutes:12% Interest on the Unpaid Installment20% Penalty on the Unpaid Installment
154CPS Indemnity ModuleThe DWC-1 must be filed within the time frames prescribed in Rule 69L-3, F.A.C. in order for the Division to monitor timely payment. Failure to timely submit forms will result in a violation as follows:$ days late$ days late$ days late$ day late$500 for over 28 days late
156CPS SystemThe Medical and Indemnity modules have the following common characteristics:System setup and site navigation.Method to review information and process data.Account administration functions.
157A few common definitions: Batch: A monthly assessment of all information submitted in one calendar month.Summary page: CPS overview of all information on an insurer’s batches.Workbench: The page where batches are processed by insurers/self insurers. This is where all “work” is done.Stage: The timeframe for the insurer/self insurer to work on the batch and respond to the Division.
158CPS StagesPreliminary Notice of Violation - The initial 30 day period for the insurer to review the Division’s identification of untimely payments and filings, to dispute/concur with the information, provide additional information or correct data, pay and resolve the batch.Notice of Violation – Administrative order by the Division to the insurer of the outstanding unresolved violations.Formal Hearing – Should the insurer dispute the violations, they can preserve their rights and request an administrative hearing.
159A few more definitions: Insurer Statuses:Dispute: The Insurer has reviewed the CPS information upon which a violation is asserted and does not agree that a violation has occurred.Concur: The Insurer has reviewed the CPS information and agrees that the violation is valid.Data Correction Sent – The insurer has sent corrected information for the CPS to review.
172Account Access RightsView Items and Add Notes: This is the basic level of permission to allow the viewing of CPS data and to add notes to CPS batches.View Items and Update Status: This secondary level of permission may view items, add notes, assign statuses of concur/dispute to preliminary violations.Submit Batches: This is the broadest permission level. Users can view items, add notes, assign statuses, and submit batches to the Division. By default this permission is given to each company’s Insurer Administrator.
174Claims Handling Entity Access Rights Claims Handling Entities (CHE) have a separate login in the Indemnity module.CHEs can view all DWC-1s submitted to the Division with their CHE code.The insurer administrator can grant higher level access to allow the CHE to respond to the violations.The CHE can do all necessary work except submit batches on the insurer’s behalf.
188Batch SubmissionWhen an insurer has responded to all violations assessed in the batch they may submit it to the Division.The Division will review the response, make any necessary data revisions/corrections, and accept or deny the insurer’s disputes.The Division will return the batch to the insurer for review.This process continues until the insurer/Division agree on the violations and payment is made or the insurer proceeds to the Notice of Violation stage.
191Batch Payment Options: There are two payment options available at any time.A Full Payment is simply the total batch payment amount.A Partial Payment is the sum of all concurred filing penalties in a batch.
209Bureau of Monitoring and Audit Today’s Discussion:Practices that Drive Audit CostsLooking Back Over The Past Year’s Audit PerformanceEvolution of the Audit Process
210Bureau of Monitoring and Audit Poor Practices that Drive Audit Costs:1. DWC-1 Untimely Filings2. Untimely Payment of Medical Bill3. Permanent Total Benefit Calculations
211Poor Practices Driving Audit Costs Timely Filing of DWC-1s:File on indemnity settlements of any typeIf Impairment Income Benefits is the first indemnity benefit paid, you must file the DWC-1 upon payment of these benefits
212Poor Practices Driving Audit Costs Timely Payment of Indemnity & Medical Benefits:Prior to January 1, % Performance StandardPost January 1, % Performance Standard
213Poor Practices Driving Audit Costs Permanent & Total Benefit Calculations:Inaccurate calculation of PT benefits & PT Supplemental benefitsTimely payment of PT benefits and PT Supplemental benefitsSocial Security Disability offset calculationsGrice limitations
214FY Audit ResultsA Summary of Audit Performances in the Following Areas:Timely Payment of IndemnityTimely Payment of MedicalTimely Reporting of the DWC-1Timely Reporting of the DWC-13Timely Sending of Employee Brochures
220Medical Bills Evaluated by CPS Since November 2004
221Latest CPS Performance Medical Data for July 2005
222Evolution of the Audit Process Our Audit Process has been Impacted by:Claims Rule (69L-3)Medical Billing Rule (69L-7.602)Upcoming EDI – Indemnity Mandate (69L-56)The Centralized Performance System1. Claims Rule Change – More Data Elements Required – Give us more ability to assess performance of payment of initial indemnity in noncontinuous and MO-LT claims.
223Evolution of the Audit Process Changing How We Review the First Report of Injury (DWC-1)Timely Reporting of the DWC-1 and Initial Indemnity Payment Assessed by CPSAudit Will Focus on Data Quality Reported to DWC (Claim File is the Source Document)
224Evolution of the Audit Process Changing How We Review Medical BillsTimely Payment and Timely Reporting of DWC-9, DWC-10, DWC-11 and DWC-90 is Now Assessed by CPSAudit Will Focus on Data Quality Reported to DWC (Claim File is the Source Document)
225New & Essential Audit Components Insurers / Claims-handling Entities Must Have Documented Processes and Procedures (in writing).Expect a Complete Review of :Step-by-Step Check Issuance2. Step-by-Step Date Stamping3. Step-by-Step Mailroom Operations
226Bureau of Monitoring and Audit IMPORTANT NOTE:Electronic Systems Must be Transparent For Audit PurposesMedical DataEDI DataPayment InformationAll Adjuster Notes / Comments
227Evolution of the Audit Process Implementation of CPS Provides More Time:Indemnity CalculationsPermanent Total CalculationsIndemnity TimelinessForensic Review of Claim File
228Bureau of Monitoring and Audit IMPORTANT NOTE:Insurers / Claims-handling Entities Must Improve the Documentation in a Claim File (If it isn’t in the claim file, you didn’t do it)
229Bureau of Monitoring & Audit Thank You!Greg Jenkins, ChiefBureau of Monitoring and AuditPhone: