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WORKERS’ COMPENSATION MONITORING PROGRAM

This article explains the responsibilities of the County Monitor in a Workers' Compensation Monitoring Program, including reviewing claims, approving payments, providing training, and conducting claim reviews. It also discusses the annual TPA audits and changes in 2009, and addresses questions about work restriction letters.

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WORKERS’ COMPENSATION MONITORING PROGRAM

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  1. WORKERS’ COMPENSATION MONITORING PROGRAM

  2. THIRD PARTY ADMININSTATORS (TPA) • TRISTAR - RANCHO (UNIT 1) • TRISTAR - SANTA ANA (UNIT 2) • INTERCARE (UNIT 3) • AIMS (UNIT 4)

  3. WORKERS’ COMPENSATIONMONITORS

  4. “The Quality Assurance Evaluator is a County employee designated as an agent for the County responsible for monitoring the Contractor’s performance, approving over limit payments, advising and training third party administrator staff in County payroll systems and other County procedures. At times this employee may be referred to as ‘County Monitor’.”

  5. DUTIES OF THE COUNTY MONITOR • Review all delayed claims at 30/60/90 day intervals • Approve all litigation referrals to County Counsel • Approve all award payments • Approve all payments over $7,500.00 • Provide training to TPA staff

  6. DUTIES OF THE COUNTY MONITOR • Assist TPA staff on balancing of complex cases • Analyze claims and provide settlement recommendations and authority • Address questions and concerns of injured workers, County departments, and defense attorneys • Attend claim reviews • Conduct annual audit of the TPA’s

  7. LIAISON BETWEEN DEPARTMENTS AND THIRD PARTY ADMINISTRATORS

  8. CLAIM REVIEWS • Reviews should be held at least quarterly with County Monitors, CEO RTW personnel, Departmental RTW personnel, Loss Control, and County Counsel. • Don’t overload! If necessary, schedule more frequent claim reviews.

  9. CLAIM REVIEWS File Selection: • Choose files with complex claims or RTW issues. • Get input from your TPA’s, County Monitors, and Counsel. • “Out of service” does not mean “out of sight, out of mind”!

  10. CLAIM REVIEWS What we need from you: • Information about any RTW efforts that have been made • Information about any disciplinary action being taken against the injured worker (unless confidential) • Information about any other action the injured worker is taking against the County (unless confidential) • Type of retirement plan • Out of service date and termination reason, if any

  11. ANNUAL TPA AUDITS • We randomly select 80 files to audit TPA performance during a defined period. • TPA’s are scored on 37 questions assigned weights based on level of importance. • A total score is calculated based on the weighted scores in each category. • There are “mutually beneficial performance and financial incentives” applied based on the total score.

  12. ANNUAL TPA AUDITS CHANGES IN 2009: • Vocational rehabilitation questions have been eliminated • New questions on: • State Panel QME Process • Supplemental Job Displacement • Work Restriction Letters

  13. WORK RESTRICTION LETTERS

  14. QUESTIONS?

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