NYS Workers' Compensation System Compliance Outreach 2015 Updates
This document provides insights into measuring and monitoring payor performance in the New York State Workers' Compensation System Compliance Outreach, focusing on timeliness of SROI reporting and initial payments. It discusses criteria for monitoring compliance, including the enforcement of the 18/10 Day Rule and late SROI report considerations. The methods for measuring timeliness of SROI showing initial payment and compensation are detailed along with the processes for determining employer knowledge dates.
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NYS Workers Compensation System Compliance Outreach: Measuring and Monitoring Payor Performance 2015 5/19/2015 Updated 9/8/15 Updated 3/9/16
5/19/2015 Agenda Introductions/ Welcome How We Are Measuring Timeliness of SROI showing Initial Payment Review of Timely Filing of SROI Report showing Initial Payment Monitoring Compliance Timeliness of SROI showing Initial Payment How We Are Measuring Timeliness of Initial Payment of Compensation Monitoring Compliance Timeliness of Initial Payment of Compensation Review of Timeliness of Initial Payment of Compensation Report Proper Filing Registration Process Questions Received Timetable Wrap-Up/ Questions
5/19/2015 3 How We Are Measuring Timeliness of SROI showing Initial Payment
5/19/2015 4 How We Are Measuring Timeliness of SROI showing Initial Payment of Compensation Enforcement of the 18/10 Day Rule defined in WCL Section 25(1)(c): If the employer or insurance carrier does not controvert the injured worker s right to compensation such employer or insurance carrier shall, either on or before the 18th day after disability, OR within 10 days after the employer first has knowledge of the alleged accident, whichever period is the greater, begin paying compensation and shall immediately notify the chair in accordance with a form prescribed by him, that the payment of compensation has begun, accompanied by the further statement that the employer or insurance carrier, as the case may be, will notify the chair when the payment of compensation has been stopped. Late SROI Report Criteria: Total number of first SROI filings per carrier per quarter DN0056 Initial Date Disability Began (18 days) DN0144 Current Date Disability Began (18 days) DN0040 Date Employer Had Knowledge of the Injury (10 days) DN0281 - Date Employer Had Knowledge of Disability (10 days) Assembly Notice Date Indexing Notice Date Received date of SROI
5/19/2015 5 How We Are Measuring Timeliness of SROI showing Initial Payment of Compensation To determine Employer Knowledge Date the Board will use the earliest date of Date Employer Had Knowledge of the Injury (DN0040), Date Employer Had Knowledge of Disability (DN0281), Assembly Notice Date, Indexing Notice Date. Initial Date Disability Began/Current Date Disability Began - If Initial Date Disability Began (DN0056) and Current Date Disability Began (DN0144) are present, and the Initial Return to Work Date (DN0068) is less than or equal to 7 days then Current Date of Disability (DN0041) is used. The SROI is Late: -If SROI received date is more than 18 calendar days from Initial Date Disability Began (DN0056) or Current Date Disability Began (DN0144); and is more than 10 calendar days from Employer Knowledge Date.
5/19/2015 6 Timeliness of SROI Report Timeliness of SROI showing Initial Payment
5/19/2015 7 Timeliness of SROI Showing Initial Payment Report New York State Workers Compensation Board Monitoring Unit Timely SROI Showing Initial Payment Summary Report Timely SROI Showing Initial Payment Received 1/1/2015 thru 3/31/2015 XYZ Ins Co Carrier Code Total during reporting period Percent Timely Average Days Late Carrier Name Timely Untimely 9 36.0% W000000 XYZ Insurance Co 25 16 4
5/19/2015 8 Timeliness of SROI Showing Initial Payment Report New York State Workers Compensation Board Monitoring Unit Timely SROI Showing Initial Payment Detail Report Timely SROI Showing Initial Payment Received 1/1/2015 thru 3/31/2015 XYZ Ins ** Date Employer Had Knowledge Date 07/10/2014 01/22/2015 08/25/2014 01/06/2015 01/30/2015 12/09/2014 01/30/2015 12/17/2014 01/19/2015 12/22/2014 01/19/2015 01/29/2015 01/15/2015 01/17/2015 01/05/2015 12/09/2014 SROI - Maint Type Code ** Initial Date Disability Began SROI Received Date Employer FEIN Claim Admin Claim Number **Date SROI Due # of days Sroi Filing is late Case Id Claim Administrator Sender Injury Date G0000000 G1111111 G2222222 G3333333 G4444444 G5555555 G6666666 G7777777 G8888888 G9999999 G1222222 G1333333 G1444444 G1555555 G1666666 G1777777 xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx xxxxxxx XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co XYZ Insurance Co IP IP IP IP IP IP IP IP IP IP IP IP IP IP IP IP 00000000 00000000 00000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 07/10/2014 01/22/2015 08/06/2014 01/06/2015 01/29/2015 12/09/2014 01/30/2015 12/16/2014 01/19/2015 12/22/2014 01/19/2015 01/29/2015 01/13/2015 01/17/2015 01/05/2015 12/12/2014 01/08/2015 01/23/2015 01/28/2015 01/09/2015 01/30/2015 12/10/2014 02/18/2015 12/17/2014 01/22/2015 12/23/2014 01/20/2015 02/04/2015 01/20/2015 01/18/2015 01/06/2015 12/12/2014 01/27/2015 02/17/2015 02/18/2015 01/29/2015 02/18/2015 01/02/2015 03/10/2015 01/08/2015 02/12/2015 01/13/2015 02/11/2015 02/25/2015 02/10/2015 02/06/2015 02/13/2015 01/09/2015 01/26/2015 02/10/2015 02/17/2015 01/27/2015 02/17/2015 12/29/2014 03/09/2015 01/05/2015 02/09/2015 01/12/2015 02/09/2015 02/23/2015 02/09/2015 02/05/2015 01/26/2015 12/30/2014 1 7 1 2 1 4 1 3 3 1 2 2 1 1 18 10
5/19/2015 9 Monitoring Compliance Timeliness of SROI
5/19/2015 10 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 SROI Pay and Report to the Chair within 18 days of disability or 10 days after employer knowledge promptly and in like manner as wages and without waiting for an award by the Board. Failure to comply will result in a penalty of $50 pursuant to 25(3)(e).
5/19/2015 11 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 implementing the following 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 TBD Timeliness of SROI showing Initial Payment TBD Timely Filing of Notice of Controversy TBD
5/19/2015 12 How We Are Measuring Timeliness of Initial Payment of Compensation
5/19/2015 13 How We Are Measuring Timeliness of the Initial Payment of Compensation Enforcement of the 18/10 Day Rule defined in WCL Section 25(1)(c): If the employer or insurance carrier does not controvert the injured worker s right to compensation such employer or insurance carrier shall, either on or before the 18th day after disability, OR within 10 days after the employer first has knowledge of the alleged accident, whichever period is the greater, begin paying compensation and shall immediately notify the chair in accordance with a form prescribed by him, that the payment of compensation has begun, accompanied by the further statement that the employer or insurance carrier, as the case may be, will notify the chair when the payment of compensation has been stopped. Late First Payment Report Criteria: Total number of first SROI filings per carrier per quarter DN0192 Benefit Payment Issue Date DN0056 Initial Date Disability Began (18 days) DN0144 Current Date Disability Began (18 days) DN0040 Date Employer Had Knowledge of the Injury (10 days) DN0281 - Date Employer Had Knowledge of Disability (10 days) DN0041 Date Claim Administrator Had Knowledge of the Injury (10 days) DN0068 Initial Return to Work Date Assembly Notice Date Indexing Notice Date Received date of SROI
5/19/2015 14 How We Are Measuring Timeliness of the Initial Payment of Compensation To determine Employer Knowledge Date the Board will use the earliest date of Date Employer Had Knowledge of the Injury (DN0040), Date Employer Had Knowledge of Disability (DN0281), Assembly Notice Date, Indexing Notice Date. To determine Date Claim Administrator had Knowledge of Injury the Board will use the earliest date of Date Claim Administrator had Knowledge of Injury (DN0041), Assembly Notice Date, Indexing Notice Date. Initial Date Disability Began/Current Date Disability Began - If Initial Date Disability Began (DN0056) and Current Date Disability Began (DN0144) are present, and the Initial Return to Work Date (DN0068) is less than or equal to 7 days then Current Date of Disability (DN0041) is used.
5/19/2015 15 How We Are Measuring Timeliness of the Initial Payment of Compensation Payment is not timely: -If Benefit Payment Issue Date (DN0192) is more than 18 calendar days from Initial Date Disability Began (DN0056) or Current Date Disability Began (DN0144); and is more than 10 calendar days from Date Employer Had Knowledge, whichever is greater. (18/10) -If Benefit Payment Issue Date (DN0192) is more than 18 calendar days from Initial Date Disability Began (DN0056) or Current Date Disability Began (DN0144); and is more than 10 calendar days from Date Employer Had Knowledge, and is more than 10 calendar days from Date Claims Administrator Had Knowledge, whichever is greater. (18/10/10) -If Benefit Payment Issue Date (DN0192) is more than 18 calendar days from Initial Date Disability Began (DN0056) or Current Date Disability Began (DN0144); and is more than 10 calendar days from Date Employer Had Knowledge, whichever is greater plus an additional 25 calendar days. (18/10 +25)
5/19/2015 16 Monitoring Compliance Timeliness of Initial Payment
5/19/2015 17 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.
5/19/2015 18 Monitoring Compliance Penalties for Late SROI and Initial Payment of Compensation WCL 25(1) When no controversy: Except in those cases when compensation is controverted, payment without an award of the Board must be made. Pay and Report to the Chair within 18 days of disability or 10 days after employer knowledge promptly and in like manner as wages and without waiting for an award by the Board [c]. Failure to comply will result in a penalty of $50 pursuant to 25(3)(e). (2)(a) When a carrier fails to file a notice of controversy or begin payment within the prescribed period or within 10 days of claims administrator knowledge (whichever period is greater), the Board may impose a $300 penalty payable to the claimant, in addition to any other penalty. (1)(e) When a carrier shall fail to pay any installment of compensation within 25 days after the said became due, a penalty of 20% of compensation then due plus $300 shall be imposed payable to claimant.
5/19/2015 19 Timeliness of Initial Payment Report Timeliness of Initial Payment
5/19/2015 20 Timeliness of Initial Payment Report New York State Workers Compensation Board Monitoring Unit First Timely Payment Summary Report First Timely Payment Received 1/1/2015 thru 3/31/2015 XYZ Ins Initial Payment (18/10) **Initial Payment (18/10/10) **Installment (18/10+25) Carrier Code Carrier Name Total during reporting period Average Days Late Average Days Late Average Days Late Percent Timely Percent Timely Percent Timely Timely Untimely Timely Untimely Timely Untimely 15 60.0% 18 72.0% 22 88.0% W000000 XYZ Insuance Co 25 10 47 7 44 3 56
5/19/2015 21 Timeliness of Initial Payment Report New York State Workers Compensation Board Monitoring Unit First Timely Payment Detail Report First Timely Payment Received 1/1/2015 thru 3/31/2015 XYZ Ins Co **Initial Payment (18/10/10) **Installment (18/10+25) **Initial Payment (18/10) ** Date Employer Had Knowledge Date **Date Claim Administrator Had Knowledge of Injury SROI - Maint Type Code ** Initial Date Disability Began Claim Admin Claim Number Benefit Pymnt Issue Date Employer FEIN Case Id XYZ Insurance Co Sender Injury Date # of days late # of days late Date Due # of days late Date Due Date Due G1111111 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 01/06/2015 01/09/2015 01/06/2015 01/09/2015 01/28/2015 01/27/2015 1 01/27/2015 1 02/23/2015 G2222222 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 12/16/2014 12/17/2014 12/16/2014 12/23/2014 01/07/2015 01/05/2015 2 01/05/2015 2 01/29/2015 G3333333 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 12/23/2014 12/24/2014 12/23/2014 01/05/2015 01/14/2015 01/12/2015 2 01/15/2015 02/05/2015 G4444444 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 01/05/2015 01/06/2015 01/07/2015 01/23/2015 01/28/2015 01/26/2015 2 02/02/2015 02/18/2015 G5555555 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 02/10/2015 02/25/2015 02/20/2015 03/09/2015 03/19/2015 03/16/2015 3 03/19/2015 04/09/2015 G6666666 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 12/27/2014 12/29/2014 12/30/2014 01/05/2015 01/20/2015 01/16/2015 4 01/16/2015 4 02/10/2015 G7777777 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 06/10/2014 06/11/2014 06/10/2014 07/01/2014 07/23/2014 06/30/2014 23 07/11/2014 12 07/24/2014 G8888888 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 01/31/2015 02/03/2015 02/02/2015 02/04/2015 03/23/2015 02/23/2015 28 02/23/2015 28 03/18/2015 5 G9999999 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 12/17/2014 12/23/2014 12/18/2014 12/26/2014 02/05/2015 01/12/2015 24 01/12/2015 24 02/04/2015 1 G0000000 0000 XYZ Insurance Co XYZ Insurance Co IP 00000000 01/13/2015 01/14/2015 01/13/2015 02/02/2015 03/02/2015 02/02/2015 28 02/12/2015 18 02/26/2015 4
5/19/2015 22 Proper Filing Proper e-claims filing
5/19/2015 23 Proper E-Claims Filing As the Board moves forward with development of its Payor Compliance Reports and implementation of eClaims, we would like to take this opportunity to provide guidance on proper eClaims filing. A SROI PD should only be used in very limited circumstances such as when the carrier has an IME indicating no disability, a medical report indicating no disability, a different site of injury than originally reported, when an employer is paying wages and the carrier is accepting the case without liability ( 21-a), when claimant fails to appear for carrier scheduled appointment per 13-a(3) or scheduled IME within the 7 day waiting period, where there is a medical report in the file that indicates the claimant will be out of work for seven days or less and there is no subsequent medical report of disability beyond the waiting period, in the rare instance where the medical evidence indicates a partial disability and the claimant has refused light duty, or in the rare instance where the claimant is losing time due to injuries on multiple claims and carrier is paying on one claim only, pending apportionment. One of the other below options are better in any other circumstance. Medical Only: When lost time does not exceed 7 days and the carrier does not initially dispute the occurrence of an accident or injury (causal relationship), the Carrier should file the FROI 00 Medical Only accepting liability for the medical portion of the claim whether there is medical in the file or not. Under eClaims rules, a SROI-04 may be filed after this Medical Only filing if lost time is claimed and investigation reveals a reason to deny the claim. SROI-IP: When the employer reports a work related accident and the lost time exceeds the waiting period whether there is medical in the file or not, payment should begin (Bob was injured at work, went to the doctor from work, called to say doctor told him to come back in 3 weeks, no work until then). FROI-04 or a SROI-4 should never be filed when the only issue is whether there is medical evidence to support a claim for compensable lost time, nor should a carrier file a denial disputing Causal Relationship when the occurrence of a work-related accident/injury is not disputed.
5/19/2015 24 Proper E-Claims Filing Payor Options When No Medical Present and the employer has reported a work related accident or injury that is expected to result in compensable lost time: Option: When there is no medical evidence in the file, the carrier may pay at the tentative mild rate pending receipt of medical from the claimant s treating provider. Option: The carrier may make payment without prejudice ( 21-a) by filing their SROI IP with agreement to compensate code without liability (DN0075) Option: When no medical evidence is produced within 48 hours of treatment, the carrier may transfer the claimant s care per 13-a (3) to an authorized treating provider in order to obtain an opinion as to degree of disability and pay benefits in accordance with the physician s opinion. Option: When no medical evidence is sent to the Board file within 30 days from the date the employer had knowledge of the date of disability (DN0281) the carrier may suspend benefits, as the inference of disability contained in the employer s initial report lasts only a reasonable time. The carrier may, of course, also suspend benefits anytime it receives a C-11 indicating the claimant has RTW. Option: The employer/carrier may choose to use a Preferred Provider Organization (PPO) in accordance with Article 10-A and 12 NYCRR 325-8.1 to 325-8.6, which requires treatment by PPO providers for the first thirty days. Option:When there is no medical evidence in the file, the carrier may choose to obtain an IME per 137 of the Workers Compensation Law.
5/19/2015 25 Proper E-Claims Filing In order to continue outreach and education on the Payor Compliance and E-Claims initiatives we ask that: If you need help determining what to file, contact the Monitoring or e-Claims Unit. monitoring@wcb.ny.gov, EClaims@wcb.ny.gov That you do not submit a denial or request a hearing, when you are unsure how to proceed. Penalties may be imposed when a denial is submitted or a hearing is requested without good reason.
5/19/2015 26 Registration Process
27 5/19/2015 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.
5/19/2015 28 Questions Received Timeliness of Initial Payment
5/19/2015 29 Questions: QUESTION: When an employer continues wages while the claimant is out on a compensable injury, how will this affects the payor s percentage of timely payments? ANSWER: If an employer is paying wages and the SROI EP is filed with the Board advising of so, the SROI EP will be deemed a timely first payment. The filing of the SROI EP will be measured for timely filing using the 18/10 rule and go towards the overall percentage. 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
5/19/2015 30 Questions: QUESTION: If a report shows that we did not make a timely payment but our research shows the payment was timely but the EDI transmission did not get accepted timely due to system issues, will consideration be given if e-claims shows failed attempts to get the transmission over timely? ANSWER: You have to pay and have an accepted report filed with the Board within the 18/10 rule. If you are having transmission issues, you could submit the report using the web application. QUESTION: If we can prove timely payment can we get credit for making a timely payment? The EDI field contains information as to when an actual payment was made; we would suggest that if you truly want to assess timely payments to injured workers you utilize data from the field showing the payment date rather than the field showing the EDI acceptance date. By doing so, you eliminate the EDI noise and are able to assess when the payment was actually made. ANSWER: Timely payment is based on the Benefit Payment Date, not the date the form was received at the Board. Timely filing of the form would be measured towards your performance.
5/19/2015 31 Questions: QUESTION: If a carrier has received information from an employer that an employee had a work related accident and lost time from work, but the lost time does not yet exceed 7 days and there is no medical in the file, will the carrier be able to object to payment of the medical bill when the medical report is submitted if it files a FROI-00 Medical Only? ANSWER: When the carrier files a FROI-00 indicating that it is accepting the case for medical only based on an employer s report, the carrier retains all rights to object to all or a portion of the medical bill for any of the reasons listed on the C-8.1 and C-8.4. QUESTION: If a carrier pays a claimant for lost wage benefits based on an employer s report of an injury with compensable lost time, and no medical report is ever received, can the employer recover the lost wage benefits paid to the claimant? ANSWER: When a carrier pays lost wages to a claimant for 30 days and thereafter suspends because no medical report is received, the payments made will be considered an overpayment on the claim subject to recovery if awards are made at a later time or the claimant receives an SLU.
5/19/2015 32 Questions: QUESTION: How will the Board measure occupational disease cases for Timely First Payment? ANSWER: If the carrier files a FROI with DN0290 Type of loss code 02 advising that the claim is an occupational disease, the case will be excluded from measurement of Timely First Report of Injury, Timely SROI showing Initial Payment, Initial Payment and Timely Controversy. .
5/19/2015 33 Upcoming Measurements
34 5/19/2015 Up Coming Measurements Timeliness of Controversy Percentage of Claims Controverted
5/19/2015 35 Tentative 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. March 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.
36 5/19/2015 Wrap Up/Questions Share your thoughts, questions and feedback with: Denise Hughes, Monitoring Program Manager Email: Monitoring@wcb.ny.gov Visit our website: http://www.wcb.ny.gov/content/main/Monitoring/Overview.jsp
