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Workers' Compensation Board

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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-808

Payor Compliance Program Update

Date: October 22, 2015

Payor Compliance Program Overview

While developing payer compliance measures, the Board has observed claim handling practices that the workers’ compensation community could review to expedite the payment of benefits to injured workers. The initial performance measures are:

  • timely filing of first reports of injury (FROIs),
  • timely first payments,
  • timely filing of reports of first payment,
  • timely filing of notices of controversy, and
  • rates of controversy.

To assist payers in developing proper compliance procedures, the Board is phasing in performance goals and penalties. All five performance measures will be included in the quarterly reports sent to payers beginning in January 2016; however, the only penalties imposed from the January 2016 report will be against the timely filing of FROIs performance goal. Penalties for timely first payments and timely reporting of first payments will begin with the report generated in April 2016; penalties for timely filing of notices of controversy will begin in the July 2016 report. Rate of controversy is being evaluated for information purposes only; at this point, there are no penalties attached to this performance goal. Payers that meet established performance goals will not be issued penalties, and all penalty notices will include an opportunity to appeal each non-compliant filing.

The performance goal for timely filing of FROIs begins at 70% and increases 5% each quarter until reaching 85%. Once set at 85%, goals will be periodically reviewed and may be increased based on statewide performance.

Proper Use Of Subsequent Report Of Injury - Partial Denial Transaction (SROI-PD)

The sole purpose of the Payor Compliance initiative is a better functioning system. In preparing for implementation, the Board reviewed submissions from employers, carriers, and third-party administrators (TPAs) to determine which would generate penalties for late FROIs and/or untimely first payments and reporting of first payments. The Board has observed that a large percentage of claims contain a subsequent report of injury-partial denial (SROI-PD) and many cite a lack of medical evidence as the reason for filing this report. Waiting for medical reports can indefinitely delay indemnity benefits that will ultimately be paid. There are a limited number of circumstances where the use of the SROI-PD is appropriate. A SROI-PD should only be filed when the payer has:

  • A medical report indicating no disability;
  • An independent medical examination (IME) indicating no disability;
  • A filing with a different injury site than originally reported;
  • An accepted claim without admitting liability per WCL § 21-a and the employer is paying the injured worker’s wages;
  • An appointment scheduled per WCL §13-a(3) or an IME scheduled within the seven-day waiting period and the injured worker failed to appear;
  • 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; or
  • A situation where the claimant is losing time due to injuries on multiple claims and the payer is paying on one claim only, pending apportionment. SROI-PD transactions cannot be used to deny medical on a claim.

Refer to the Monitoring and Compliance section of the Board’s website for specific scenarios on proper filings. (http://www.wcb.ny.gov/content/main/Monitoring/Overview.jsp)

Additional Types Of Filings

The following describes when to use other filings.

Medical Only

When lost time does not exceed seven days, the claim administrator should file the FROI accepting liability for the medical portion of the claim. This filing may also be used as a pay without prejudice medical only filing; the claim administrator may later file a denial if lost time is claimed. This can also be used when there is no evidence regarding the claim. A medical only filing is not appropriate when the employer reports that there is compensable lost time. For example, a worker was injured at work, went to the doctor, and called the employer to say that the doctor told him to come back in ten days with no work until then. In that example, an Initial Payment (SROI-Initial Payment) indicating payment to the injured worker should be filed as described in the next paragraph.

SROI-IP

Payment should begin when the employer reports a work-related injury/illness and lost time exceeds the waiting period, whether there is medical claim in the file or not. When a work-related illness/injury is not disputed, it is inappropriate for the claim administrator to file a denial disputing Causal Relationship. The following options are available, in addition to the SROI-IP:

  1. If there is no medical evidence in the file, the payer may pay at the tentative mild rate for 30 days, pending receipt of medical evidence from the treating provider. If no medical evidence is sent to the Board within 30 days from the date the employer had knowledge of the date of disability, the payer may suspend benefits as the inference of disability contained in the employer’s initial report only lasts for a reasonable time. The payer may, of course, also suspend benefits anytime it receives an Employer’s Report of Injured Employee’s Change in Status or Return to Work (Form C-11) indicating the injured worker has returned to work.
  2. If the injured worker’s selected treating health care provider has not filed a medical report of first treatment within 48 hours of the treatment, the payer may deem it in the interest of the injured worker to transfer the injured worker’s care to an authorized treating health care provider in order to obtain an opinion about the degree of disability and pay benefits in accordance with the health care provider’s opinion per 13-a (3).
  3. The Claim Administrator may procure an IME.
  4. The Claim Administrator may consider using WCL § 21-a to pay the claim without prejudice.

For monitoring purposes, when a SROI-PD is followed by a SROI-IP, the filed date of the SROI-IP is the date used for to determine timely filing, regardless if there is medical evidence in the file.

FROI-04/SROI-04

A FROI-04 or a SROI-04 should never be filed when the only issue is if there is medical evidence to support a claim for compensable lost time.

SROI Maintenance Codes

A SROI Maintenance Type Code (MTC) is to be used when a claim administrator is denying indemnity, in part or in whole, on a claim.

Questions regarding this release may be addressed to the Bureau of Compliance, Monitoring Unit, 328 State Street, Schenectady, New York, 12305; email to Monitoring@wcb.ny.gov.

 

Robert E. Beloten
Chair