NYS Workers’ Compensation System

Compliance Outreach: Measuring and Monitoring Payor Performance

2015

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Agenda

• Introductions/ Welcome

• Background

• Key Performance Indicator (KPI): How We Are MeasuringTimeliness of First Report of Injury (FROI)

• Review of First Report of Injury Report

• Monitoring Compliance

• Registration Process

• Questions from Previous Webinar

• Timetable

• Wrap-Up/ Questions

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Background• eClaims Project –

• Started in 5/13 with full participation by 4/14, provides the Board with the data needed to monitor system participant performance within several Workers’ Compensation system key performance measures/indicators.

• Mission of the Board’s newly created Monitoring Unit• To promote excellence in claims handling practices and provide

system participants and the general public with information as to claims handling performance.

• Role of the Boards newly created Monitoring Unit

• Educate system participants on performance standard metrics• Monitor the quality and quantity of system participants data

submissions. • Monitor and audit filings and payment performance.• Identify system participants who are not complying with

performance standards and issue penalties, if appropriate. • Using information captured to educate and train system participants

to improve overall performance within the Workers’ Compensation system.

How we are Measuring:

Timeliness of the First Report of Injury (FROI)

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KPIs: How We Are MeasuringTimeliness of the First Report of Injury Filing

• Education on the 18/10 Day Rule defined in NYCRR Section 300.22 : “On or before the 18th day after the disability event OR within 10 days after the employer has knowledge of the disability event, whichever period is greater, the carrier, Special Fund, self-insured employer or TPA shall file electronically a First Report of Injury (FROI) with the Board.”

• "Disability event" means any accident, including death resulting therefrom, occurring in the course of employment or any alleged accident, including death resulting therefrom, that results in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident or alleged accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid; or any disease or alleged disease, including death resulting therefrom, claimed to have been caused by the nature of the employment and contracted therein.

Note: A C-2F Form filed by an employer with the Board does not satisfy the carrier’s requirement to file a FROI.

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KPIs: How We Are MeasuringTimeliness of the First Report of Injury Filing

• The Board will begin to measure First Report of Injuries on only lost time claims. Due to this the timeline will be 18 days from Date of Accident, 10 days from Date Employer had Knowledge of Injury, 10 days from Initial Date of Disability, whichever period is greater.

• To determine Employer Knowledge Date the Board will use the earliest date of DN0040 Date Employer Had Knowledge of the Injury, DN0281 Date Employer Had Knowledge of Disability, Assembly Notice Date, Indexing Notice Date.

• Late Filing of FROI Report Criteria:Total number of FROI’s with lost time filed by carrier per quarterReceived date of Initial FROIDate of Accident (18 days)DN0040 – Date Employer Had Knowledge of the Injury ( 10 days)DN0281 – Date Employer Had Knowledge of Disability (10 days)Assembly Notice Date (10 Days)Indexing Notice Date (10 days)DN0056 – Initial Date Disability Began (10 days)

(Definition -The first day qualifying as a day of disability in the first period of disability. This will be the first day of the waiting period).

First Report of Injury (FROI) Report:

Summary and Detail

First Report of Injury Summary Report

New York State Workers’ Compensation Board Monitoring UnitFirst Report of Injury Detail Report

First Report of Injury (FROI) Received or Due 01/01/2015 thru 03/31/2015Run Date:

04/03/2015

Carrier Code: WXXXXXX Carrier Name: XYZ Insurance Co

Carrier Code Carrier NameTotal during

reporting period

Timely Untimely Percent Timely FROI Filing Average

Days Late

WXXXXXX XYZ Insurance Co 13 8 5 61.5% 13 25

First Report of Injury Reports

New York State Workers’ Compensation Board Monitoring UnitFirst Report of Injury Detail Report

First Report of Injury (FROI) Received or Due 01/01/2015 thru 03/31/2015Run Date:

04/03/2015

Carrier Code: WXXXXXX Carrier Name: XYZ Insurance Co.

Case Id Claim Administrator Sender FEIN # FROI# Carrier Case Id Injury Date

Date Employer

had Knowledge of

the Injury

Date Employer

had Knowledge of Date of Disability

Assembly or Indexed

Notice DateInitial Date of

DisabilityDue Date of

FROIReceived

Date of FroiNumber of Days

Late

G1111112 XYZ Insurance Co XYZ Insurance Co 123456789 666666 WC000000 12/14/2014 12/14/2014 12/14/2014 02/09/2015 12/15/2014 01/02/2015 02/04/2015 33G1111113 XYZ Insurance Co XYZ Insurance Co 123456789 777777 WCS111111 01/09/2015 01/10/2015 01/10/2015 02/13/2015 01/10/2015 01/27/2015 02/20/2015 24G1111114 XYZ Insurance Co XYZ Insurance Co 123456789 888888 WC2222222 01/17/2015 01/17/2015 01/17/2015 02/11/2015 01/19/2015 02/04/2015 02/06/2015 2G1111115 XYZ Insurance Co XYZ Insurance Co 123456789 999999 WC3333333 01/18/2015 01/18/2015 01/18/2015 03/30/2015 01/18/2015 02/05/2015 03/25/2015 48G1111116 XYZ Insurance Co XYZ Insurance Co 123456789 555555 WC4444444 01/21/2015 01/21/2015 01/21/2015 03/16/2015 02/08/2015 02/18/2015 03/11/2015 21

Monitoring Compliance

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Monitoring Compliance

The Board expects to use penalties as the last step of the process. Payors will have sufficient time to work with the Board to understand where they are out of compliance and the steps that can be taken to avoid penalties.

• Penalty for Late FROI Filings

• WCL §25 (3)(e) If the carrier or employer fails to file a notice or report requested or required by the Board or otherwise required within the specified time period or within 10 days if no time period is specified, the Board may impose a $50 penalty.

Monitoring Compliance

Performance Standards:

• WCL §25 (3)(e) If the carrier or employer fails to file a notice or report requested or required by the Board or otherwise required within the specified time period or within 10 days if no time period is specified, the Board may impose a $50 penalty.

The Board is planning to implement performance standards:

The penalty under §25(3)(e) will not be imposed as long as a carrier meets the below performance standards per category. Your filings will be measured for each category, per quarter, against the performance standard. If the performance standard is met in that category your §25(3)(e) penalty will be waived.

Timely First Report of Injury at TBD

Timely First Payment at TBD

Timely Filing of Notice of Controversy at TBD

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Registration Process

Registration Process

All Carriers, Self-Insureds and Municipalities would need E-claims Inquiry access.

In order to get E-claims Inquiry access please register on line at

http://www.wcb.ny.gov/content/ebiz/eclaims/Registration/howtoregInquiry.jsp

Payor Compliance Agreement will need to be signed in order to review Payor Compliance Reports.

• Payor Compliance Agreement will be an electronic document• A Payor Compliance Agreement will be signed for access per W-code (may list

multiple W-Codes on one agreement)• Please send name and e-mail address of executive officer for each W-code to

monitorregistration@wcb.ny.gov in order to receive Payor Compliance Agreement for signature

Once the Payor Compliance agreement is signed and approved by the Board, anyone with e-claims Inquiry Access for that W-code (carrier or TPA) would then be able to see the Payor Compliance Reports.

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Up Coming Measurements

• Timeliness of Initial SROI showing Initial Payment

• Timeliness of Initial Payment of Compensation

• Timeliness of Controversy

• Percentage of Claims Controverted

Questions Received From Focus Group:

In Regards to FROI

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Questions:

QUESTION:Why can’t the First Report of Injury penalty be applied against the employer and not the carrier? ANSWER:The Board is tracking both the employer knowledge date along with the claims administrator knowledge date. Initially no penalties will be imposed against the employer. After an initial time period, all penalties available under the law will be considered including when appropriate, WCL 110 (4) against the employer.

QUESTION:If the date the form is due falls on a Saturday, Sunday or Holiday will the Board consider it timely on the next business day?

ANSWER:Yes

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Timetable

Sept. 2014- Measurement criteria defined/sample reports drafted

November 2014 – March, 2015- Begin outreach to system participants and dashboard programming

January 1, 2015- Monitoring Unit develops an Enforcement Plan for Timely First Report of Injury, Timely First Payment and Timely Controversy.

April 2015 – Advise all system participants of new process

April 2015- September 2015 - TRIAL PERIOD (6 months)- Reports generated and distributed to all system participants

Oct 1, 2015- System goes live

January 2016 – 2015 4th quarter reports and penalties generated and distributed to all system participants.

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Wrap-Up/Questions

• Share your thoughts, questions and feedback with:Denise Hughes, Monitoring Program Manager

Email: Monitoring@wcb.ny.gov