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County of Los Angeles Workers’ Compensation TPA Performance Evaluation Meeting

County of Los Angeles Workers’ Compensation TPA Performance Evaluation Meeting. Dates: November 12, 2010 (Unit 2) November 19, 2010 (Unit 1) December 03, 2010 (Unit 3) December 21, 2010 (Unit 4) January 18, 2011 (RTW Seminar). Workers’ Compensation Claim Volume.

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County of Los Angeles Workers’ Compensation TPA Performance Evaluation Meeting

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  1. County of Los Angeles Workers’ Compensation TPA Performance Evaluation Meeting Dates: November 12, 2010 (Unit 2) November 19, 2010 (Unit 1) December 03, 2010 (Unit 3) December 21, 2010 (Unit 4) January 18, 2011 (RTW Seminar)

  2. Workers’ Compensation Claim Volume

  3. Impact of 2003-2004 Legislation

  4. Workers’ Compensation Expenses Excludes LC 4850 & SC

  5. LC 4850

  6. Benefit Expense Type

  7. Factors to Consider (Medical)

  8. Workers’ Compensation Program GoalOperational Effectiveness • Strategy 1: Fiscal Sustainability • Strategy 2: Service Excellence and Organizational Effectiveness • Promote the sound and expedient delivery of workers’ compensation benefits through evidenced based claims administration (communication, documentation, and timeliness). (SOW 1.0 & 1.2) • Maintain accurate and thorough decision logs to ensure compensability of injuries and illnesses are made in accordance with State Workers’ Compensation laws. (SOW 1.2.2) • Ensure decisions to provide and/or approve benefits related to medical need are based on the treating physician’s recommendations and MTUS (examiners must know the triggers). (SOW 1.3 & 2.4) • Maintain close liaison with the treating physician and County department to promote the early-return-to-work process by procuring meaningful temporary work restrictions. Submit a request for Temporary Work Restriction Letter to the treating physician on or near the 30th day of disability. (SOW 1.3 & 1.7)

  9. Workers’ Compensation Program GoalOperational Effectiveness • Strategy 1: Fiscal Sustainability • Strategy 2: Service Excellence and Organizational Effectiveness • Report, monitor, and actively address issues (action plans) related to claims where state rate temporary disability benefits are paid (see Workers’ Compensation Long-Term Leave memo – 10/26/2010). (SOW 1.7 & 2.1) • Ensure the timeliness and accuracy of all work restriction letters. (SOW 1.7) • Establish and maintain an adequate separation of duties between personnel who process and enter payment, address, and vendor data. Ensure management utilize reports to periodically (at least monthly) verify compliance with such processes. Secure and maintain confidentiality of all workers’ compensation claim information. (SOW 1.9) • Utilize the Medical Treatment Verification form in a timely and logical manner to evaluate potential billing abuse or fraud.

  10. Workers’ Compensation Program GoalOperational Effectiveness • Strategy 1: Fiscal Sustainability • Strategy 2: Service Excellence and Organizational Effectiveness • Customer service – provide accurate information and guidance to injured workers on benefits directed by state law in a respectful and prompt manner. Respond to injured worker and department inquiries as soon as necessary. However, in no event shall the response be provided later than 24 hours from the inquiry. (SOW 1.4) • Provide sufficient and competent staff to fulfill the contract and establish an effective management and organizational structure. (SOW 2.3)

  11. WC TPA Generated Reports • TPA Memo 10/26/10 • Open Claim Report A • Open Claim Report B • TD Paid Report

  12. Emphasis on Disability Management • Sound Long-Term Leave Management Protocols • FEHA Compliance Efforts • Early-Return-To-Work Efforts (Transitional Modified Work) • Return-To-Work Efforts (Permanent Placement in Modified or Alternate Positions) • Los Angeles County Probation (Unit 4)

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