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Compliance with Maine Workers’ Compensation Board Requirements. 2004-2008 Maine Workers’ Compensation Board Office of Monitoring, Audit and Enforcement. How is Compliance Measured? Monitoring. the timely filing of: Lost Time First Report of Injury (FROI)

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compliance with maine workers compensation board requirements

Compliance with Maine Workers’ Compensation Board Requirements

2004-2008

Maine Workers’ Compensation Board

Office of Monitoring, Audit and

Enforcement

how is compliance measured monitoring
How is Compliance Measured?Monitoring
  • the timely filing of:
    • Lost Time First Report of Injury (FROI)
    • Initial Memorandum of Payment (MOP)
    • Initial Indemnity Notice of Controversy (NOC)
  • the timely payment of:
    • Initial Indemnity Payment

The Maine Workers’ Compensation Board measures

how is compliance measured monitoring1
How is Compliance Measured?Monitoring
  • Insurance entity compliance information is published in:
    • 4 Quarterly Compliance Reports
    • 1 Annual Compliance Report
  • Individual entity and insurance community compliance data is published and analyzed for trends
how is compliance measured auditing
How is Compliance Measured?Auditing
  • Insurance entities are audited on a random schedule for filing compliance on all forms
  • 3 year cycle
  • Penalties are imposed for each occurrence and prosecution for questionable claims-handling may take place
what are the compliance measurements
What are the Compliance Measurements?

FROI - (LT claims only) must be filed:

  • Within 7 days of Employer’s Notice or Knowledge of Incapacity (Box 43B on FROI)

TA or TE date

MINUS Box 43B

= less than 8 days

what are the compliance measurements1
What are the Compliance Measurements?
  • Initial MOP Filing
    • Received Within 17 days of Employer’s Notice or Knowledge of Incapacity
    • MOPs must be sent within 14 days of Employer’s Notice or Knowledge of Incapacity.
  • NOC Filing
    • Received within 14 days of Employer’s Notice or Knowledge of Incapacity

(A NOC is not received until you get a TA or a TE.)

what are the compliance measurements2
What are the Compliance Measurements?
  • All other forms not measured in compliance report
    • Are measured by Auditing in their samples
    • Filing requirements are available in the Maine Workers’ Compensation Act, MWCB Rules and Regulations, MWCB Forms Manual, and the MAE Protocols
maine compliance lost time first reports of injury filing compliance
Maine ComplianceLost Time First Reports of Injury Filing Compliance

Benchmark

Insurance industry in Maine has performed above 80% for the last five years. The MWCB benchmark is 85%.

maine compliance initial indemnity payments compliance
Maine ComplianceInitial Indemnity Payments Compliance

87% BENCHMARK

The insurance industry in Maine has been at or above benchmark in payment compliance for the last five years.

maine compliance initial mop filing compliance
Maine ComplianceInitial MOP Filing Compliance

85% BENCHMARK

The insurance industry in Maine has been above benchmark for the last five years. (The benchmark prior to 2008 was 75%.)

maine compliance initial indemnity noc filing compliance
Maine ComplianceInitial Indemnity NOC Filing Compliance

The insurance industry in Maine met the benchmark established in 2008. No benchmark existed for this form filing prior to this year.

medical payment compliance
Medical Payment Compliance

Reimbursement

The employer/insurer shall pay the health care provider's charge or the maximum allowable payment under this fee schedule, whichever is less, within 30 days of receipt of a bill unless the bill or previous bills from the same provider or the underlying injury has been controverted or denied.

medical payment compliance1
Medical Payment Compliance

Penalties

If the medical bills are not paid within 30

days after the carrier has received notice of

nonpayment by certified mail, penalties will also

accrue.

($50 or the amount of the bill due, whichever

is less, for each day over 30 days in which

the bills were not paid. Not more than $1,500

in total may be added.)

why is compliance important
Why is Compliance Important?
  • Poor compliance can trigger audits and/or Corrective Action Plans (CAP)
    • CAPs are agreements and action plans between MWCB and the Insurer/Adjuster to improve poor compliance and improve claims handling
    • Failure to engage in a CAP can result in prompt audit
why is compliance important1
Why is Compliance important?
  • Compliance data is published for:
    • Internal Customers (Claims Management, Executive Management)
    • External Customers (Regulators, Competitors, Claimants)
why is compliance important2
Why is Compliance important?
  • Penalties can result
    • From $1 to infinity and beyond!
  • Excessive late filing can be interpreted as questionable claims-handling
  • Under §359, an insurer, self-insurer, TPA or adjuster can have their license revoked by the Bureau of Insurance
compliance benchmarks
Compliance Benchmarks

MWCB Issued Performance Benchmarks Effective 1/1/08

  • Filing of FROI

New Benchmark-85% Old Benchmark–None

  • Initial Indemnity Payment

New Benchmark-87%. Old Benchmark–80%

  • Filing of Initial MOP

New Benchmark-85%. Old Benchmark-75%

  • Filing of Initial Indemnity NOC

New Benchmark-90%. Old Benchmark-None

board contacts
Board Contacts
  • Auditing

Helen Eagen – (207) 287-5481

Marlene Swift – (207) 287-7014

  • Claims Management

Sherrill Creamer – (207) 287-2002

  • Monitoring

Kathy Schulz – (207) 287-7268

Brad Howard – (207)287-7350