California’s Division of Workers Compensation (DWC) recently released a pair of important announcements for the public.
DWC has posted an example of a streamlined End of Medical Provider Network (MPN) Coverage Notice to the DWC website.
This streamlined notice is only used when an employer-based or insurer-based MPN ends its coverage and consolidates medical care into an MPN established by an entity that provides physician network services and the medical treatment of injured workers is not affected. Medical treatment will not be affected if the underlying network of providers is used by all of the MPNs involved.
Since an injured worker’s medical treatment will remain with the same physician and continue with the MPN that is taking over medical care, a Transfer of Care Notice pursuant to California Code of Regulations, title 8, section 9767.9 is not required.
However, a complete employee notification must be provided pursuant to California Code of Regulations, title 8, section 9767.12(a), along with the streamlined End of Medical Provider Network (MPN) Coverage Notice. This sample gives three options to choose from to provide the complete employee notification.
Profile Audit Review Needed
In other DWC news, Labor Code §§129 and 129.5 require the Audit Unit of the Division of Workers Compensation (DWC) to conduct a profile audit review (PAR) for all adjusting locations of California workers comp claims at least once every five years.
Performance of the adjusting locations is measured in five areas of claims administration:
• The payment of accrued and undisputed indemnity
• The late first payment of temporary disability / first notice of salary continuation
• The late first payment of permanent disability and death benefits
• The late subsequent indemnity payments
• The provision of notices with QME/AME advice.
The administrative director annually establishes profile audit review and full compliance audit (FCA) standards in accordance with Labor Code §§129(b)(1) and (2) and Title 8, California Code of Regulations §10107.1. The 2015 standards are based on the audit results of calendar years 2011 through 2013.
Performance standards for 2015:
• The PAR performance standard for audits conducted in 2015 is 1.53446. Audit subjects with PAR performance ratings of 1.53446 or lower will be required to pay any unpaid compensation, but no penalties will be assessed. If an audit subject’s PAR performance rating is 1.53447or higher, the audit will expand to a FCA, and an additional sample of indemnity claims will be audited.
• The FCA performance standard for audits conducted in 2015 is 1.68525. Audit subjects with an FCA performance rating of 1.68525 or less will be required to pay any unpaid compensation and penalties will be assessed for all violations involving unpaid and late paid compensation. If an audit subject’s full compliance audit performance rating is 1.68526 or higher, an additional sample of denied claims as well as the expanded sample of indemnity claims will be audited.
Penalties will be assessed for all violations as appropriate pursuant to 8CCR §§10111 through 10111.2.
Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com. Contact: [email protected].
©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.
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