Managing Your Claims: Part I€¦ · Workers’ compensation claims are accepted (Form 60), denied...

Managing Your Claims: Part 1

Workers’ Compensation Administrator Training

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Introduction• Emergency Exit Plan

• Morning And Afternoon Breaks

• Lunch (1 Hour)

• Introductions of Trainers and Participants

• Explanation of Training Materials

• Visit www.workerscomp.nc.gov for many resources

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http://www.workerscomp.nc.gov/

NC OSHR Workers’ Compensation Website & Email Address

Go to:www.workerscomp.nc.gov

Click on:“Check Out the WCA Resources”

Email Address:[email protected]

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What’s on the website

• Standard Operating Procedures

• Business Process Charts

• Job Aids

• Forms

• Vendor Information

• …and much more

AgendaIntroductionModule 1 Initial Injury Handling and ReportingModule 2 Incident InvestigationsModule 3 Claim Acceptance and Denial DecisionsModule 4 Return To Work Module 5 Workers’ Compensation Benefits, Leave, and

Effect on Other BenefitsModule 6 Claims MonitoringModule 7 Detecting Fraud and AbuseModule 8 Close Claims Timely and FairlyModule 9 Recording Workers’ Compensation Actions

in BEACONModule 10 Agency Quarterly Performance Reports

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Introduction

NEW Vendor Contracts effective January 1, 2016 – December 31, 2018

VENDOR LIST

Third Party (Claims) Administrator/Medical/Pharmacy/Bill Review: CorVel (contractor representative on site at OSHR)

Medical/Nurse Case Management/Vocational Rehabilitation: Carolina Case ManagementCorVelSouthern Rehabilitation, Inc.

Surveillance:Advantage Surveillance, Inc.DJG Investigative Services, Inc.G4S

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Introduction

Carolina Case ManagmentSouthern Rehab

Nurse/Medical & Vocational Case Management

CorVelThird Party Administrator,

PPO/Medical Provider Network,Pharmacy Benefits Manager,

Bill Review/ Utilization Review,

1/3 Nurse/Vocational Case Management

Advantage SurveillanceDJG Investigative Services

G4SSurveillance Services

Bills & Reports

Bills & Reports

Payments toVendors

Payments to Injured

Employees

Bills & Reports to Agencies

Payment forClaim Costs

($$$)

Office of State Controller (OSC)

WORKERS’ COMPENSATIONCLAIM PROCESS

Agency WCA coordi-nates light duty job with injured employee’s supervisor.

Employee returns to work with or without permanent restrictions, or employee is separated.

TPA coordinates employee’s ongoing medical treatment until claim is closed.

TPA files all required forms withIndustrial Commission.

Agency WCA may approve NCM and VR inaccordance withestablished protocols.

Agency WCA may select surveillance vendor and works with TPA to direct surveillance activities.

If claim needs final settlement, TPA prepares settlement evaluation, agency WCA sets authority and directs process with AG advice and representation.

KEY

TPA Third Party Administrator AG Attorney GeneralOSHR Office of State Human Resources WCA Workers’ Compensation AdministratorMMI Maximum Medical Improvement HR Human Resources

NC Office of State Human Resources

Agency WCA reports suspicious activity/potential fraud toTPA & OSHR.

If motion filed/hearing requested on disputed issue, AG represents agency.

If employee at MMI returns to work with permanent partial disability rating, rating paid & claim closed.

Supervisor completes Incident Investigation Report and gives to agency WCA.

Supervisor reports injury to Agency WCA.Agency WCA electronically reports injury to TPA.

Agency makes final decision to accept/ deny/pay claim without prejudice.

TPA performs investi-gation and recommends accept/deny/pay claim without prejudice.

Agency WCA forwards Incident Investigation Report to TPA and agency safety officer/committee.

Supervisor administers First Aid or directs employee to initial medical treatment.

Employee reports injury to supervisor.

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Workers’ Compensation Flow of Information

Employee with Compensable

WC Claim

TPA & Other

Vendors

Agency Workers’ Compensation Administrator

OSHR

Attorney General Represents state

agencies in WC litigation

NC Industrial Commission

Workers’ Compensation court for handling of disputes and

benefit awards Plaintiff’s or employee’s attorneys

represent injured employees in WC

litigation

Litigation filings

Forms & Agreement Filings

Litigation filings

Litigation filings

Litigation filings

Litigation filings

Bills, Reports & Information


Ongoing Communication



Ongoing Communication

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Workers’ Compensation Billing & Payment Process

Step 1: CorVel sends 2 monthly invoices to OSHR:(a) Claims costs; and (b) TPA fees sorted by agency.

Step 2: OSHR forwards invoices to OSC.Step 3: OSC forwards invoices to individual agencies.Step 4: Agencies reconcile monthly bills and forward corrections

directly to CorVel for credits.Step 5: Agencies pay monthly by transferring funds to OSC.Step 6: OSC transfers funds DAILY to WC bank account per

CorVel request.Step 7: CorVel writes checks DAILY and mails to medical

providers, pharmacy/case management/surveillance vendors, Industrial Commission, employees, etc.

ELECTRONIC FUNDS TRANSFER TO VENDORS AND EMPLOYEES NOW BEING IMPLEMENTED!!!

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Electronic Funds Transfer

•EFT to vendors and employees was implemented August 1, 2016.

•EFT is not mandatory; it is strictly opt-in.

•Those that do not sign up for EFT will still receive paper checks.

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Module 1: Initial Injury Handling and Reporting

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Module 1Initial Injury Handling & Reporting

•Business Process Chart

•Locating In-network Medical Providers

•Entering FNOLo JOB AID – Initial Injury Handling/

Claim Reporting/Investigation Checklist

o Industrial Commission Form 19

Module 1

•Instruct supervisors to use the OSHR “Injury Data Collection Form” available at www.workerscomp.nc.gov

•PDF fillable form may be completed, saved, and emailed, or printed and faxed to WCA.

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Initial Injury Handling & Reporting


LEO Salary Continuation-Determine eligibility and do required letters, if applicable.

If employee removed from work, supervisor provides employee’s job description to TPA.

TPA reviews claim report, assigns adjuster, conducts investigation, and recommends claim approval or denial.

Agency WCA forwards Incident Investigation package to TPA and agency safety officer/ committee immediately upon receipt.

Initial Claims Reporting to TPA

KEY

TPA Third Party Administrator IC Industrial CommissionOSHR Office of State Human Resources HR Human Resources

WCA Workers’ Compensation Administrator LEO Law enforcement officer

NC OSHR Workers’ Compensation Current Business Process

Supervisor completes Incident Investigation Report and gives package to agency WCA within 48 hours of injury.

Supervisor completes OSHR Injury Data Reporting Form or other agency Injury Report form and gives to agency WCA.

Supervisor interviews employee and witnessesand gets their written statements.

Agency WCA completes entire FNOL Injury Report in TPA web portal for injury requiring formal medical treatment.

Supervisor obtains copy of Work Note given to employee by authorized medical provider.

If treatment is required, supervisor generates treatment Authorization form & goes with employee to authorized medical provider.

If First Aid/no formal medical treatment needed, agency WCAcompletes “Report Only” section of FNOL in TPA web portal stopping at line 18a.

Injured employee reports injury to supervisor on duty.

Module 1

Report Only Claims

•Complete all required FNOL information under “Report an Incident/Injury”

•Select “Yes” on Line 18a for a Report Only claim (first aid, no medical treatment)

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Initial Injury Handling & Reporting

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CorVel

•ONLY stores the claim

•NO charge

•NO review

•NO letters

•NO phone calls

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UNLESS……….

•Employee needs medical treatment

•Employee files Form #18 with the Industrial Commission

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Medical Treatment Claims

•Complete all required FNOL information under “Report an Incident/Injury”

•Select “No” on Line 18a for “Report Only” which will begin a “Medical Treatment” claim

•CorVel will charge for appropriate claim type

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CorVel does the following:

•Will immediately begin handling completed claim

•Will review the claim

•Will send form letter within 2 business days of receipt of completed claim

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• Will file Form 19, Employer Report of Injury, with the Industrial Commission if:o Any lost time from work; ORo More than $2,000 medical bills

• Will charge TPA fee in accordance with claim type:o Medical Only - $170.00o Medical Complex (Denied) - $380.00o Indemnity - $975.00

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KEY POINTS1. Agency WCAs should maintain an updated list of medical

providers for initial referral of injured employees in all locations. Ensure all supervisors at each location have access to an updated list at all times.

2. Agency WCAs should submit ALL injury reports to TPA via online web portal, www.caremc.com, using “Report an Injury/incident” module as soon as possible after receiving notice that an injury has occurred.

3. There is no TPA charge associated with filing a “Report Only” claim (i.e. no medical treatment, aside from first aid, is expected).

http://www.caremc.com/

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Module 2: Incident Investigations

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Module 2Incident Investigations

State of NC Incident Investigation & Reporting Program

• 22 page form & guidebook that includes:1. Roles and responsibilities2. Instructions for completion3. Blank employee statement form4. Blank witness statement form5. Blank supervisor investigation report form

• Download or print by visiting www.workerscomp.nc.govand click on the blue box: “Check Out the WCA Resources”


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Step 1:Supervisor visits accident scene (if possible), takes pictures, preserves surveillance video, gathers additional information about what happened before and after accident, and consults with safety staff as needed.

Step 2: Supervisor gathers written employee and witness statements.

Module 2

Step 3:Supervisor performs Root Cause Analysis (Focus of Investigation)

HOW TO: Ask “Why” 5 times to determine what really caused the injury.

Root Cause requires identifying all hazards involved to determine the cause of the accident and correct all identified hazards to prevent future accidents.

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Incident Investigations

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Step 4:Supervisor completes incident investigation process ideally within 72 hours of injury and gives complete report to agency WCA.

Step 5:Agency WCA sends complete Incident Investigation Report to:

a. Agency Safety Officer/Committee; and b. CorVel medical only or indemnity adjuster.

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Available BEACON LMS Incident Investigation TRAINING CLASSES

1. OSHR Safety: Incident Investigation & Reporting Procedures – Module A – Employees

2. OSHR Safety: Incident Investigation & Reporting Procedures – Module B – Supervisors

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Module 3: Claim Acceptance & Denial Decisions

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Module 3Claim Acceptance & Denial Decisions

• IC Form 60 – Accept

• IC Form 61 – Deny

• IC Form 63 – Pay without prejudice to later deny or accept

Does additional information indicate that

claim should be accepted?

Adjuster files Form 60 with I.C. accepting claim and sends copy to employee and/or

attorney.

YES NO

NO

YES

NO

Adjuster files Form 61 with I.C. denying claim

and sends copy to employee and/or

attorney.

Does information indicate that claim should be accepted?

For a maximum of 90-120 days, adjuster and workers' compensation administrator continue claim investigation including taking recorded statements, evaluating

additional medical records, legal research, etc. and make compensability decision.

Claim Acceptance

orDenialTree


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1. Workers’ compensation claims are accepted (Form 60), denied (Form 61) or paid without prejudice to later deny or accept (Form 63) following investigation.

2. The TPA recommends a claim compensability decision; agencies have final decision making authority.

3. When in doubt about the compensability of a claim, you may always file Form 63 to pay without prejudice and continue investigating for up to 120 additional days before making a compensability decision.

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Module 4: Return to Work

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Module 4Return to Work

Return to Work is:1. A proactive process; early intervention is key.

2. Opportunity to prevent “learned disability”.

3. Opportunity for employees and management to jointly control the economic and personal costs of work-related injuries.

Ongoing communication between employee and employer is key!

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Supervisors/WCAs, please inform injured employees:

• Return To Work is a part of the claim process, NOT the end of it.

• Return To Work does not mean medical treatment ends for their work related injury/condition.

• When you Return To Work, you will still be able to attend medical appointments scheduled during the workday without using sick leave.

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Why do we want to pay employees to stay away from work?

Employees out of work due to injury receive Temporary Total Disability (TTD) benefits:

a. Weekly Compensation Rate (66 2/3% of average weekly wages); or

b. Salary Continuation (Eligible employees only that meet requirements)

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Return To Work = Closing Cases & Saving $$$

Employees using RTWPs

succeedEmployee feels

needed and wanted

Greater chance of recovery

Lower chance

employee will hire attorney

Employee doesn’t get

used to easy money

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1. What is “Suitable Employment”?

2. Agency Return to Work Program Implementation

Module 4

What is “suitable employment? It depends.Determining factors:

1. Has employee reached maximum medical improvement (MMI) or end of healing period for work-related injuries?

2. What is the date of injury?

a. On or before June 23, 2011

b. On or after June 24, 2011

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Return to Work

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Today’s focus: Return To Work or “suitable employment” for claims arising on or after June 24, 2011

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PRE-Maximum Medical Improvement

Modified Duty Return to Work can be “Make Work”

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Pre-MMI “suitable employment” (Modified Duty) job must:

1. Be within work restrictions.2. Be with employer of injury.3. Be approved by authorized treating physician.

Written approval not required, but may be advisable given facts and litigation potential.

4. Be offered by employer.

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THINK OUTSIDE THE BOX

• Think about the individual’s abilities

• Think beyond the typical duties

• Think value added

• Think skill enhancement

• Think mentoring

• Think special projects

• Think cross training


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How much does the employee get paid when performing Pre-MMI Light/Modified/Restricted Duty?

1. Full salary for hours worked.

2. Temporary Partial Disability (TPD) benefits: Employee’s weekly compensation rate or 66 2/3% of pre-injury average weekly wages for hours not worked based on 40 hour work week.

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Secondary Employment

DID WORKsecond job prior to injury, within work restrictions

DID WORKsecond job prior to injury, NOTwithin work restrictions

DID NOTwork second job prior to injury, within work restrictions

DID NOT work second job prior to injury, NOTwithin work restrictions

Pre-MMI (still in healing period; temporary work restrictions)

WC disability benefits continue.

WC disability benefits subject to being suspended by ICuntil discontinue second job.

WC disability benefits subject to being reduced or suspended by IC dependent on wages earned.

WC disability benefits subject to being suspended by IC until discontinue second job.

What about Pre-MMI secondary employment?

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Post-MMI “suitable employment” for employees assigned permanent work restrictions:

1. Employee capable of performing work considering:a) Preexisting limitationsb) Injury-related physical and mental limitationsc) Vocational skillsd) Educatione) Experience

2. Located within 50-mile radius of employee’s home on date of injury or current residence with legitimate reason to relocate.

3. No single factor will be considered exclusively in determining suitable employment.

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• The following ARE NOT relevant for whether job is “suitable employment”:

• This narrowed definition makes it easier to locate new jobs for employees with permanent work restrictions

• Authorized treating physician approval of a permanent job description is NOT NECESSARY

• Wages• Benefits• Hours• Age

• Vocational interests• Aptitudes• Local labor market• Shifts

Module 4

What about Post-MMI secondary employment? It’s complicated.

Contact your adjuster or OSHR with specific case facts and we will provide you with guidance on how to best proceed when an employee reaches MMI, has permanent work restrictions, and/or has secondary employment.

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Return to Work

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“Risk management” factors to consider:1. Employee’s medical records for all work injuries.

2. Employee’s overall physical condition/other medical problems.

3. Risk of employee having IBA/STI while performing proposed job duties.

4. Risks of injury to others if employee performs proposed job duties.

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Work restrictions accommodated for 90 days.

Return To WorkSupervisor discusses modified duty work with HR and agency WCA.

If LE, obtain clearance from LE Medical Office, may need requalification.

Supervisor reviews authorized treating physician’s assigned work restrictions in Work Note to identify appropriate modified duty work in agency.

Supervisor reassesses modified duty work assignment following receipt of each Work Note.

Employee gives supervisor copy of new Work Note following each visit with authorized treating physician.

Process BEACON action for em-ployee returning to work.

Supervisor meets with employee to discuss and sign modified duty work agreement.

Employee returns to pre-injury job with accommodations, or other “suitable employment” within agency or state government.

If employee reaches MMI and is assigned work restrictions, supervisor, agency WCA, and HR review job description and work restrictions.

If employee reaches MMI and is assigned no permanent work restrictions, returns to pre-injury position.

Modified duty status reviewed at 90 day mark for projected duration.

Employee may be separated if unable to perform job functions.

If “suitable employment” cannot be identified, vocational rehabili-tation may be assigned, settle-ment may occur, or workers’ compensation benefits continue.

KEY

LE Law Enforcement MMI Maximum Medical Improvement

WCA Workers’ Compensation Administrator HR Human Resources


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Return to Work Job Aids

• Return To Work ChartsHow to use: Ask 2 questions

1. Is employee at MMI? Go to applicable chart.

2. What is employee’s date of injury? Go to applicable column on chart.

• Ten Fast Facts About Return To Work And Suitable Employment

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Return To Work Program Implementation

“OSHR Return To Work Program Implementation Guide”

available at www.workerscomp.nc.gov

Step by step guide with extensive explanations of how to implement and maintain a successful Return To Work program that ensures all injured employees are given return to work opportunities.

Includes lists, charts, sample documents including an actual Return To Work program.


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Job Aid: 8 Steps to a Successful Return To Work Program

1. Management Support

2. Agency Return To Work Committee (Policies, Procedures)

3. Education of Workforce (Incentives, Accountability)

Educate Employees About RTW Program

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• Communicate the concept, benefits, and importance to all employees on an ongoing basis

• Explain the Return To Work program as a benefit

• Explain the Return To Work process

• Create a Return To Work culture

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Job Aid: 8 Steps to a Successful Return To Work Program, continued

4. Maintain Inventory of Pre-Identified Modified Duty Work for Pre-MMI work

It can be anything!

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Pre-MMI Work Examples1. Taking inventory2. Planting flowers3. Filing projects4. Observing a space5. Answering a phone6. Word processing/database projects7. Researching

Modified Duty Employment Plans

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• Written agreement with detailed description of work signed by employee and supervisor.

• Have a beginning and ending date.

• Are reviewed periodically and may change dependent upon assigned work restrictions and circumstances (Usually 90 day limit, but agencies have flexibility.)

• Focus on employee’s abilities.

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Job Aid: 8 Steps to a Successful Return To Work Program, continued

5. Communication with Medical Providersa. Establish working relationships with initial

medical providers.b. Clearly communicate need for detailed

Return To Work notes with precise work restrictions.

Module 4


6. Maximum Medical Improvement

Two options:

a. Released to Full Dutyb. Permanent Work Restrictions =

Can “suitable employment” be found?i. Old job with accommodationsii. New job in same agencyiii. New job with different public or private sector

employer

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Return to Work

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Agency Post-MMI Job Placement Programs

1. Prior to injured employee reaching MMI, begin evaluating whether permanent work restrictions can be accommodated in pre-injury job.

a. If “Yes”, start planning for potential job modificationsb. If “No”, start identifying potential agency jobs within employee’s

assigned work restrictions

2. After employee reaches MMI and has been assigned permanent work restrictions, identify job vacancies that meet definition of “suitable employment”.

3. Determine if employee meets minimum qualifications and has knowledge, skills, and abilities for identified job vacancies.

4. Determine if employee will be a “good fit” in the potential new job.

Do not set up injured employees to fail!

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Have questions or need help with finding a new job for an employee who has reached MMI and been assigned permanent work restrictions that CANNOT be accommodated in pre-injury job?

Adjusters, agencies, case managers may refer claims to CorVel Return To Work Coordinator, Andy Russell, at (919) 740-1244 for assistance with identifying what available jobs in an agency meet the definition of “suitable employment”.

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7. Vocational RehabilitationWill it work? If so, start early.

8. Program EvaluationWhat works and what does not?

Recognize Success

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• Get feedback on process from:• Employee

• Supervisor• WCA• Adjuster

• Recognize individual departments that proactively bring employees back to work

• Thank supervisors who aggressively seek RTW opportunities

Salary Continuation – NCGS §143-166.14

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Salary continuation eligibility standard for all claims arising on or after July 1, 2015 for eligible persons listed in statute:

“The salary of any eligible person shall be paid as long as the person's employment in that position continues, notwithstanding the person's total or partial incapacity to perform any duties to which the person may be lawfully assigned, if that incapacity is the result of an injury or injuries resulting from or arising out of an episode of violence, resistance, or due to other special hazards that occur while the eligible person is performing official duties...”

Session Law 2015-241 Section 30.18(c)

Salary Continuation Eligibility List NCGS §143-166.13

1. Security Officers

2. Correctional Officers

3. Probation and Parole Officers

4. Law Enforcement Officers

5. Highway Patrol Officers

6. General Assembly Special Police

7. Juvenile Justice OfficersInsurance Investigators

8. Inspectors and Special Investigators

9. NC Ports Authority Police

10. Driver License Examiners

11. Employees injured by an offender in a state correctional facility

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See NCGS §143-166.13 for complete list of eligible people

Salary Continuation – NCGS §143-166.14

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What is the amount of the Salary Continuation benefit per NCGS §143-166.14?

For all claims eligible for salary continuation benefits arising on or after July 1, 2015:“the term "salary" shall be defined as the total base pay of the person reflected on the person's salary statement and shall not include overtime pay, shift differential pay, holiday pay, or other additional earnings to which the person may have been entitled prior to such incapacity.”Session Law 2015-241 Section 30.18(c)

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New “Separation” Rule

Effective April 1, 2016“..notwithstanding any unexhausted applicable leave credits and leave benefits, when an employee is on workers’ compensation leave of absence, and the employee is unable to return to all of the position’s essential duties and work schedule due to a medical condition or the vagueness of a medical prognosis, and the employee and the agency are unable to reach agreement on a return to work arrangement that meets both the needs of the agency and the employee’s medical condition a separation may occur on the earliest of the following dates: (i) after the employee has reached maximum medical improvement for the work related injury for which the employee is on workers’ compensation leave of absence and the agency is unable to accommodate the employee’s permanent work restrictions related to such injury; or (ii) 12 months after the date of the employee’s work related injury…”

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Module 5: WC Benefits, Leave & Effect on Other Benefits

Module 5WC Benefit Checklist

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______ Seven days waiting period before disability compensation may begin ______ Leave options for seven (7) days waiting period until TTD or TPD compensation begins ______ Supplemental Leave option while on Workers’ Compensation Leave ______ Medical treatment while on workers’ compensation leave will be directed by the

employer/third party administrator ______ Requirement to give Work Status notes to supervisor immediately upon receipt from

authorized treating physician ______ Temporary Total Disability (TTD), Temporary Partial Disability (TPD), Permanent

Partial Disability (PPD) compensation ______ Light/Modified/Transitional Duty Return To Work requirements ______ State Service/Pay Status ______ Health Insurance ______ Sick Leave

______ Vacation Leave ______ Longevity Pay ______ Performance Increases ______ Salary Continuation (if applicable) ______ Retirement Service Credit ______ Disability Income Plan

For additional information on these topics, contact your agency Health/Benefits representative.

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Module 5WC Benefits Checklist Signatures

I, ___________________________________, certify that I have received information regarding workers’ compensation benefits, employment status, and benefits from an authorized representative of my employing agency. I understand that I may direct additional questions to the workers’ compensation administrator or health/benefits representative(s) in my agency.

Signature of Injured Employee:_______________________Date: ____________

Signature of Agency Representative:__________________Date: ____________

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Module 5WC Benefits, Leave & Effect on Other Benefits

• NC State Government WC Employee Handbook

• Revised Forms:1. EE Use of Leave Options Form

2. EE Release of Information – Medical & Claim Records

3. EE Release of Information – Personnel Records

Module 5WC Benefits, Leave & Effect on Other Benefits

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KEY POINTS1. Agencies must ensure injured employees on WC leave receive the

“NC State Employee WC Handbook” which includes detailed information regarding their WC benefits, leave policy, and how their leave status affects other employment benefits

2. An agency WCA and/or HR Benefits Representative should speak personally and preferably meet in person with injured employees to answer any questions regarding WC benefits, leave policy and how their status affects other employment benefits.

3. Agencies should obtain the following signed documents from the injured employee on WC leave (preferably during an in-person meeting to discuss benefits):a) Benefits checklist used during discussion with agency WCA/HBR

representativeb) Employee Leave Option Form with Overpayment agreementc) HIPAA Release of Medical Information

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Module 6: Claims Monitoring

Module 6

Claims Monitoring Spreadsheet

• Claim Information

• Return To Work

• Medical Treatment

• Case Management

• Legal Status

• Claim Closing

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Claims Monitoring

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Module 6Claims Monitoring

Look in CareMC to find the following documents in each claim file:

• 45 Day Claim Review for Indemnity Claims

• 90 Day Claim Review for Indemnity Claims

These are summaries of important claim elements related to the injured employee’s medical treatment, return to work status, and plan for claim closing.

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JOB AID – When to file Form 24

1. Suspend Compensation2. Terminate Compensation

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JOB AID:

Critical Claim Progression Points for Cost Containment

3 Main Categories

1. Return to Work2. Claim Closing3. Other

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KEY POINTS1. Agency WCAs should actively monitor ALL open WC claims for

return to work, medical status, case management, legal status and claim closing information.

2. An injured employees immediate supervisor should maintain ongoing communication with the employee regarding their return to work status to ensure the employee knows they are a valued team member that will be welcomed back to work with or without temporary or permanent work restrictions.

3. Agency WCAs should communicate with assigned TPA administrator claim adjusters when critical claim progression points arise to ensure they are promptly addressed.

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Module 7: Detecting Fraud and Abuse

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Module 7Detecting Fraud and Abuse

What are the RED FLAGS that indicate potential workers’ compensation fraud or abuse?

1. Employee Characteristics

2. Injury Related Matters/Circumstances

For detailed list, see the Job Aid adapted from article in August 6, 2010 edition of Pursuit entitled “Top 40 Red Flags Which May Indicate Workers’ Compensation Fraud” by Scott Fulmer.

Surveillance Authorization

TPA confers with agency WCA and OSHR if needed regarding surveillance report and takes appropriate action.

Surveillance vendor performs services and sends investigative reports to TPA, agency WCA, and OSHR.

KEY

WCA Workers’ Compensation Administrator TPA Third Party Administrator

TPA, agency WCA, and surveillance vendor develop detailed surveillance plan based on all relevant information.

TPA contacts surveil-lance vendor and forwards completed information form

Agency WCA selects approved surveillance vendor and sends OSHR surveillance referral information form to TPA adjuster.

If agency initially disapproves surveillance, TPA may seek OSHRrecommendation for surveillance.

TPA seeks agency WCAapproval for surveillance.

TPA and agency WCA analyzes information received from any source regarding credibility of employee’s claim.

Agency WCA makes final decision regarding need for surveillance.


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Module 7Detecting Fraud and Abuse

Agency selects Surveillance vendor:1. Advantage Surveillance, Inc.2. DJG Investigative Services3. G4S

2 Types of Surveillancea. Cyber or internet investigationb. In-person/On-site

• Surveillance results will be tracked to study what methods work best and yield the most useful evidence for the least cost.

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Module 8: Close Claims Timely & Fairly

Module 8

Business Process Charts

1. Form 26A

2. Settlement/Clincher

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Close Claims Timely & Fairly

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Complete Form 26A PPD Payment

Process

Employee may participate in vocational rehabilitation,

if needed.

Does employee receive offer of “suitable employment”?

File Form 28B as soon as possible.

File Form 28B upon completion of all medical and disability compensation payments.

File Form 24 to terminate

compensation (TTD), Form 62 to modify compensation

(TPD), and complete Form 26A process to pay PPD, if owed.

Settle case via compromise settlement agreement.

File Form 28C upon settlement payment.

File Form 28B upon completion of all medical and disability compensation payments.

YES NO

YES

NO NO

YES

NO

Keep claim open and continue paying compensation.

OR

YES

Has employee returned to full duty work or job modified to accommodate

permanent work restrictions?

Module 8: Close Claims Timely & Fairly

TPA sends signed Form 26A and medical records to IC for approval.

TPA completes Form 28B within 16 days of last payment of medical or disability compensation and sends to IC and employee.

NCIC Form 26A (PPD) Payment Process

Employee or agency WCA may request second opinion on PPD rating from physician of choice at employer’s expense.

Employee returns to full duty work at pre-injury or another job.

Authorized treating physician determines employee at MMI and issues PPD rating in medical note or on Form 25R.

Agency WCA reviews Form 26A, signs, and sends to TPA.

Employee returns signed Form 26A to agency WCA or TPA (whichever entity sent it to employee).

TPA prepares Form 26A and sends with medical records to agency WCA or employee for signature.

Employee, TPA, and agency WCA agree on PPD rating to be paidand notify TPA.

TPA issues periodic or lump sum PPD payment check(s) to employee/attorney.

TPA notifies agency WCA of Form 26A approval.

IC approves Form 26A and sends approval notice to TPA.

KEY

TPA Third Party Administrator IC Industrial CommissionMMI Maximum Medical Improvement PPD Permanent Partial Disability

WCA Workers’ Compensation Administrator


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Case SettlementIf employee is eligible for LTD, HR sends letter or contacts employee regarding eligibility.

If eligible, employee should already be on STD running concur-rently with WC.

Employee separated, has resigned, has been RIFed, has been terminated, salary continuation has ended, or permanent work restrictions cannot be accommodated.

Case settled by parties or at mediation with agency represented by AG.

If claim settlement greater than $75,000, TPA must obtain authorization from AG’s office before settlement negotiation.

If claim settlement less than $75,000, TPA/AG negotiates settlement and agreement reached.

Agency WCA obtains settlement authoriza-tion from agency and notifies TPA of approved amount.

TPA prepares case settlement evaluation including MSA amount, if applicable, and submits to agency WCA.

KEY

TPA Third Party Administrator STD/ LTD Short-Term/Long-Term disability

MSA Medicare Set Aside IC Industrial Commission

AG Attorney General (NCDOJ -Workers’ Compensation Section) WCA Workers’ Compensation

AdministratorHR Human Resources RIF Reduction-in-force

MMI Maximum Medical Improvement


Upon receipt of approved clincher agreement, AG’s office forwards copyof approval Order to TPA and agency WCA for payment processing.

TPA sends large payment request, if applicable, to agency requesting funds transfer in advance toOSC while clincher is pending at IC.

AG forwards signed clincher agreement and required attachments to IC for approval with copy to TPA and agency WCA.

After employee signs, AG sends signed clincher agreement to agency WCA for signature.

AG sends clincher agreement to employee for signature.

TPA forwards settlement information to AG for clincher agreement preparation.

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Module 8Close Claims Timely & Fairly

KEY POINTS1. PPD benefits should be paid as quickly as possible to start the

two (2) years statute of limitations.

2. The claim settlement process varies for individual claims but should always include consideration of the following factors: a) TTD eligibility unlimited (lifetime) or subject to 500 week capb) Age/life expectancyc) Retirement eligibilityd) Short Term Disability/Long Term Disability eligibilitye) Potential current or future Medicare eligibilityf) Potential current or future Social Security Disability eligibilityg) Future medical treatmenth) Permanent work restrictionsi) Vocational rehabilitation potential

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Module 9: Recording Workers’ Compensation Actions in BEACON

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Module 9Recording Workers’ Compensation Actions in BEACON

Identified Challenges - WC Leave Recording1. Incorrect WC LOA recording

2. Late WC LOA recording

3. Not recording WC LOA at all

Improper WC LOA recording results in overpayments of wages that are very difficult to recover.

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• WCAs should work closely with supervisors and payroll staff to ensure all WC LOA Actions and Notes are recorded correctly and in a timely manner.

• BEACON view only access will allow WCAs to properly oversight accuracy and timeliness of WC leave actions.

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BEACON Rules for WC Actions

1. You are not required to enter a Leave of Absence (LOA) action to account for an employee’s Worker’s Compensation 7 Day Waiting Period prior to employee’s eligibility for temporary total disability (TTD) benefits.a. Track the 7 day waiting period offline while it is

occurring.b. When a WC Leave of Absence action is recorded,

include a note with all dates of the 7 day Waiting Period.

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Pending BEACON Rules for WC Actions Coming Soon

2. A WC Leave of Absence action should be processed regardless of length of time if an employee is being paid disability compensation benefits for lost time by CorVel. (i.e. TTD or TPD)

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Module 10: Agency Quarterly Performance Reports

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Module 10Performance Measures

Agency Workers’ Compensation Measures

1. First Notice of Loss Reporting To Third Party Administrator Lag Time: How many days between date of injury and date claim report to CorVel (TPA) is completed?

GOAL: Report all injuries/incidentswithin 48 hours of injury.

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2. Return To Work Lag Time: How many days between the authorized date of the injured employee’s release to return to work with light/modified/transitional duty restrictions or permanent restrictions and actual date of return to work.

GOAL: Return To Work as soon as released.

Module 10


3. Workers’ Compensation Leave Actions Numbercompleted within a monthly payroll cycle compared to those effective during that payroll cycle.

GOAL: Record WC LOA action as soon as effective.

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Performance Measures

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4. Number of injuries reported for each agency.

5. Active claims for each agency sorted by job and injury type.

OSHR SHWC CONTACT INFORMATION

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Safety, Health & Workers’ Compensation DirectorJohn Bogner, Jr., [email protected] (919) 807-4897

State Workers’ Compensation ManagerScarlette Gardner, Esq. [email protected] (919) 807-4858

Safety and Health ManagerDoug Gaylord, [email protected] (919) 807-4877MSOS, CHMM, MESH

Workers’ Compensation ConsultantsCynthia Leeks [email protected] (919) 807-4855Michelle Morgan [email protected] (919) 807-4866LuNeta Vaughan [email protected] (919) 807-4848

State Safety ConsultantKathy Conner [email protected] (919) 807-4824

mailto:[email protected]







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