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WORKERS’ COMPENSATION MONITORING PROGRAM. THIRD PARTY ADMININSTATORS (TPA). TRISTAR - RANCHO (UNIT 1) TRISTAR - SANTA ANA (UNIT 2) INTERCARE (UNIT 3) AIMS (UNIT 4) . WORKERS’ COMPENSATION MONITORS.

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WORKERS’ COMPENSATION MONITORING PROGRAM


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third party admininstators tpa
THIRD PARTY ADMININSTATORS (TPA)
  • TRISTAR - RANCHO (UNIT 1)
  • TRISTAR - SANTA ANA (UNIT 2)
  • INTERCARE (UNIT 3)
  • AIMS (UNIT 4)
slide4

“The Quality Assurance Evaluator is a County employee designated as an agent for the County responsible for monitoring the Contractor’s performance, approving over limit payments, advising and training third party administrator staff in County payroll systems and other County procedures. At times this employee may be referred to as ‘County Monitor’.”

duties of the county monitor
DUTIES OF THE COUNTY MONITOR
  • Review all delayed claims at 30/60/90 day intervals
  • Approve all litigation referrals to County Counsel
  • Approve all award payments
  • Approve all payments over $7,500.00
  • Provide training to TPA staff
duties of the county monitor6
DUTIES OF THE COUNTY MONITOR
  • Assist TPA staff on balancing of complex cases
  • Analyze claims and provide settlement recommendations and authority
  • Address questions and concerns of injured workers, County departments, and defense attorneys
  • Attend claim reviews
  • Conduct annual audit of the TPA’s
claim reviews
CLAIM REVIEWS
  • Reviews should be held at least quarterly with County Monitors, CEO RTW personnel, Departmental RTW personnel, Loss Control, and County Counsel.
  • Don’t overload! If necessary, schedule more frequent claim reviews.
claim reviews9
CLAIM REVIEWS

File Selection:

  • Choose files with complex claims or RTW issues.
  • Get input from your TPA’s, County Monitors, and Counsel.
  • “Out of service” does not mean “out of sight, out of mind”!
claim reviews10
CLAIM REVIEWS

What we need from you:

  • Information about any RTW efforts that have been made
  • Information about any disciplinary action being taken against the injured worker (unless confidential)
  • Information about any other action the injured worker is taking against the County (unless confidential)
  • Type of retirement plan
  • Out of service date and termination reason, if any
annual tpa audits
ANNUAL TPA AUDITS
  • We randomly select 80 files to audit TPA performance during a defined period.
  • TPA’s are scored on 37 questions assigned weights based on level of importance.
  • A total score is calculated based on the weighted scores in each category.
  • There are “mutually beneficial performance and financial incentives” applied based on the total score.
annual tpa audits12
ANNUAL TPA AUDITS

CHANGES IN 2009:

  • Vocational rehabilitation questions have been eliminated
  • New questions on:
    • State Panel QME Process
    • Supplemental Job Displacement
    • Work Restriction Letters