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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. the timely filing of: Lost Time First Report of Injury (FROI)

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Compliance with Maine Workers’ Compensation Board Requirements

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  1. Compliance with Maine Workers’ Compensation Board Requirements 2004-2008 Maine Workers’ Compensation Board Office of Monitoring, Audit and Enforcement

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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.)

  7. 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

  8. 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%.

  9. Third quarters are always problematic for compliant filing of First Reports. Maine Compliance Lost Time First Reports of Injury Filing Compliance

  10. 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.

  11. 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%.)

  12. 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.

  13. 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.

  14. 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.)

  15. 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

  16. Why is Compliance important? • Compliance data is published for: • Internal Customers (Claims Management, Executive Management) • External Customers (Regulators, Competitors, Claimants)

  17. 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

  18. 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

  19. Maine ComplianceReview Questions??

  20. 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

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