Winning The Gold… Audit Unit Updates. COSIPA Presented by Cora Lee Southern California Supervisor DWC-Audit Unit 3/11/10 and 3/25/10. Winning the Gold…. Labor Code (LC) §129 . Audits To assure prompt and accurate provision of benefits
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Presented by Cora Lee
Southern California Supervisor
3/11/10 and 3/25/10
Labor Code (LC) §129. Audits
LC §129.5 Administrative and Civil Penalties, Schedule of Violations
The Annual Performance Standard is set by industry performance in five areas of claims administration
Violations for late-paid indemnity affect the factors for the performance rating of a PAR audit subject
If 10% self-imposed increase (SII) is owed, it is to be paid with the late paid TD or PD [LC§4650(d)]
Failure to comply with regulations for the provision of the AME/QME and/or SJDB advice affects Factor #5 for the performance rating of a PAR audit subject 8CCR§10107.1(c)(3)(E)
Faulty Benefit Notices
There is exposure for penalty:
Note: As of April 9, 2008, there is exposure for provision of AME/QME advice in many of the benefit notices
Unpaid indemnity frequently results from failure to:
Avoid unpaid indemnity
Revised (c)(5) When a PAR rating fails to meet or exceed the PAR performance standard, the AU will provide written notification of intention to proceed to a FCA of indemnity files. The audit subject must provide factual basis for dispute of the rating within 2 working days of receipt of rating or during the post-PAR conference.
(c)(3)(B) The factor for the late first payment of temporary disability indemnity shall be determined by dividing the number of randomly selected claims with violations involving the late first payment of TD by the number of randomly selected claims in which TD payments were issued
in claims that involve salary continuation, by dividing the number of randomly selected claims involving a failure to comply with the requirements for first notices of salary continuation
the number of randomly selected claims in which TD payments or first notices of SC were required.
Revised (h) The AU will not assess penalties for violations of failure to make payment of indemnity due if the total indemnity is less than twenty-five dollars ($25.00) aggregate per claim. Although penalties may not be assessed, the audit subject shall pay all indemnity due.
Revised(a)(10) When failing to comply with an award or order of the WCAB, RU or AD
Revised(b)(10) The penalty for failure to pay or object, as required by law or regulation, to a bill for medical treatment provided or authorized by TP
Revised(b)(24) The penalty for failure fully and/or timely comply with any final award or order of the WCAB, the RU or the AD not assessed under 8CCR§10111.2(a)(10)
New(b)(27) The penalty for failure to comply with the SJDB notice requirements of 8CCR§10133.51
New(b)(28) The penalty for failure to issue the voucher for education-related training/skill enhancement in accordance with 8CCR§13133.56(c) unless employer complies with LC §4658.6
New (b)(30) For claims reported on or after April 19, 2004, regardless of the date of injury, the penalty for each failure to authorize medical treatment for which the employer is responsible under LC §5402(c) is $2,500
6. Pay interest and increase on late-paid medical treatment and medical-legal expenses
A faxed answer to the requesting physician fulfills the verbal and written requirements. Keep a copy of the transmittal sheet.
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E-mail: [email protected]Winning the Gold…