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Workers’ Compensation Claims Adjuster Regulations

Workers’ Compensation Claims Adjuster Regulations. Insurance Code Section 11761 and Title 10, California Code of Regulations Section 2592, et seq ., effective February 22, 2006. Insurance Code Section 11761.

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Workers’ Compensation Claims Adjuster Regulations

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  1. Workers’ Compensation Claims Adjuster Regulations Insurance Code Section 11761 and Title 10, California Code of Regulations Section 2592, et seq., effective February 22, 2006

  2. Insurance Code Section 11761 • The commissioner shall adopt regulations setting forth the minimum standards of training, experience, and skill that workers' compensation claims adjusters must possess to perform their duties with regard to workers' compensation claims. The regulations adopted pursuant to this section shall, to the greatest extent possible, encourage the use of existing private and public education, training, and certification programs. • Every insurer shall certify to the commissioner that the personnel employed by the insurer to adjust workers' compensation claims, or employed for that purpose by any medical billing entity with which the insurer contracts, meet the minimum standards adopted by the commissioner pursuant to subdivision (a).

  3. Insurance Code Section 11761 (continued) • For the purposes of this section, "medical billing entity" means a third party that reviews or adjusts workers' compensation medical bills for insurers. • For the purposes of this section, "insurer" means an insurer admitted to transact workers' compensation insurance in this state, the State Compensation Insurance Fund, an employer that has secured a certificate of consent to self-insure pursuant to subdivision (b) or (c) of Section 3700 of the Labor Code, or a third-party administrator that has secured a certificate of consent pursuant to Section 3702.1 of the Labor Code.

  4. Who is an Insurer? • Insurer Admitted to write workers’ compensation in California • SCIF • Self-Insured Employer • Third-Party Administrator per Labor Code Section 3702.1 [for self-insured employer] Insurer defined in Subdivision (d) of Insurance Code Section 11761

  5. Who is NOT an Insurer? • Medical Billing Entity • Third-Party Administrator for Admitted Insurer

  6. Certification to theInsurance Commissioner • Each Insurer shall certify to the Insurance Commissioner annually on or before July 1 that they have complied with the requirements established by these regulations. • Only Insurers are to certify; not medical billing entities. • Certification format contained in regulations. • Two Certifications: Claims Adjusters and Medical Bill Reviewers.

  7. Training and/or Experience • Claims Adjusters and Medical Bill Reviewers can either meet training or experience requirements to be Designated by an Insurer to adjust California Workers’ Compensation Claims. • A person can adjust or review medical bills for up to 12 consecutive months during training while under the supervision of an instructor or experienced claims adjuster.

  8. Training Requirements • Claims Adjusters: 160 hours of training with 120 hours conducted in classroom with an instructor. • Medical-Only Claims Adjuster: 80 hours of training with 50 hours conducted in classroom with an instructor. • Medical Bill Reviewer: 40 hours of training with 30 hours conducted in classroom with an instructor.

  9. Training Requirements • Training must be completed within 12 consecutive months, with certain exceptions. • Classes taken 3 years prior to the effective date of these Regulations can apply to the hourly requirements upon verification of the Insurer.

  10. Instructors and Classrooms • Instructors must qualify as Experienced Claims Adjusters or have 8 years in the last 12 years of experience in California workers’ compensation. • Classroom means a place where there is privacy and little outside interference so that students and the instructor can communicate. • Classroom also includes the use of electronic medium, such as audio, video, computer, or Internet.

  11. (1) Historical overview of the workers' compensation system. (2) Organizational structure of the system. (3) The workers' compensation insurance policy, its forms and endorsements, insurance principles of compensation. (4) Concepts and terminology. (5) Benefit provisions. (6) Compensability. (7) Notice requirements. (8) Temporary disability. (9) Permanent disability, including evaluation and rating. (10) Death benefits. (11) Return to work and vocational rehabilitation. (12) Cumulative trauma. (13) Serious and willful misconduct. (14) Workers’ Compensation Appeals Board procedures, forms, hearings, and penalties. (15) Investigation. (16) Fraud. (17) Medical terminology. (18) Knowledge and use of utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation.) (19) Medical evidence. (20) Medical dispute resolution (Qualified Medical Examiners, spinal surgery second opinions, pre-designation of physicians, independent medical reviewers, utilization review.) (21) Fee schedules. (22) Liens. (23) Apportionment. (24) Subrogation. (25) Reserving. (26) Ethical issues. Curriculum Topics for Claims Adjusters

  12. Curriculum Topics for Medical-Only Claims Adjusters Same as for Claims Adjusters, except (8) Temporary disability. (9) Permanent disability, including evaluation and rating. (10) Death benefits. (11) Return to work and vocational rehabilitation. (13) Serious and willful misconduct. (23) Apportionment.

  13. Curriculum Topics for Medical Bill Reviewers (1) The correct use of billing codes and detection of improper use of billing codes. (2) All fee schedules applicable in California to workers' compensation medical care, including statutes and regulations authorizing the fee schedules. (3) Workers' compensation benefit provisions. (4) Fraud. (5) Medical terminology. (6) Utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation.) (7) Medical evidence. (8) Liens. (9) Ethical issues.

  14. Experience A person may handle workers’ compensation claims based upon experience only and without initial training • Experienced Claims Adjuster: 5 years in the last 8 years of on-the-job experience adjusting or supervising California WC Claims; or Complete the Self-Insurance Exam and (1) worked as claims adjuster or supervisor continuously since the exam or (2) passed the exam within the last 5 years.

  15. Experience(continued) • Experienced Medical-Only Claims Adjuster: 3 years in the past 5 years of on-the-job experience adjusting California workers’ compensation medical-only claims. • Experienced Medical Bill Reviewer: 3 years in the past 5 years of on-the-job experience adjusting California workers’ compensation medical bills.

  16. Designations • An Insurer will Designate their claims adjusters, medical-only claims adjusters, and medical bill reviewers to handle workers’ compensation claims based upon completion of training or experience. • Designations can be transferred from one insurer to another insurer with proper documentation. • Records of Designations can be obtained by claims adjusters or bill reviewers from previous insurers employing or using them • Copies of Designations are available to employers or claimants to verify the qualifications of claims adjusters or medical bill reviewers.

  17. Post-Designation Training Following Designation by an Insurer, a claims adjuster, medical-only claims adjuster, or bill reviewers must maintain required continuing education every 2 years and receive a Post-Designation Training Form • Claims Adjusters must complete 30 hours every two years. • Medical-Only Claims Adjusters must complete 20 hours every two years. • Medical Bill Reviewers must complete 16 hours every two years. Post-Designation Training should cover curriculum topics and current changes to the law. Post-Designation Training can be obtained through classes, seminars, workshops, etc., and does not have to be done in a classroom with an instructor. The 3 year retrospective for Designation training courses does not apply to Post-Designation Training.

  18. Do I Need Post-Designation Training? Failure of a Claims Adjuster, Medical-Only Claims Adjuster, or Medical Bill Reviewer to maintain the required hours of Post-Designation Training shall result in that person being no longer considered Designated. That person shall not be authorized to adjust claims or medical bills until the requisite number of hours of Post-Designation Training is completed.

  19. Maintenance of Records • Insurers are required to maintain copies of Designation and Post-Designation Training Forms for all claims adjusters and medical bill reviewers employed or working on their behalf. • Insurers are required to maintain training course records for both Designation and Post-Designation training. • Designation and training records are to be made available to claims adjusters and medical bill reviewers and other insurers employing them. • Records are to be maintained during the period that the claims adjuster or medical bill reviewer is employed or utilized by the insurer and for 5 years thereafter.

  20. Maintenance of Records • DO NOT SEND TRAINING OR DESIGNATION RECORDS TO THE INSURANCE COMMISSIONER. • ONLY SEND Certification Forms to: California Department of Insurance, Producer Licensing Bureau Education Unit, 320 Capitol Mall, 1st Floor, Sacramento, CA 95814; Telephone (916) 492-3064.

  21. Remaining Issues and Thoughts • Insurers DO include Property and Casualty Insurers that write workers’ compensation for domestic workers per Insurance Code Section 108.1 and Labor Code Section 3351(d). • Insurers will be self-administering their own training and post-designation programs according to the regulations training, curriculum, and topic requirements. Records are to be maintained for audit by CDI or DWC. • Insurers, as defined, are responsible for certifying to the Insurance Commissioner and maintaining proper records to support those certifications and cannot rely upon third parties.

  22. Remaining Issues and Thoughts(continued) • Only Certifications shall be sent to the Insurance Commissioner and NOT the supporting documentation. • Claims Adjusters and Medical Bill Reviewers should maintain their own documentation of Training, Designation, Post-Designation Training for future reference.

  23. Questions ? Contacts at Department of Insurance Christopher Citko, Senior Staff Counsel (916) 492-3187; citkoc@insurance.ca.gov Brian Bugsch, Policy Office Manager (916) 492-3506; bugschb@insurance.ca.gov

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