WORKERS’ COMPENSATION MONITORING PROGRAM. THIRD PARTY ADMININSTATORS (TPA) TRISTAR - RANCHO (UNIT 1) TRISTAR - RANCHO (UNIT 1) TRISTAR - SANTA ANA (UNIT.

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Presentation transcript:

WORKERS’ COMPENSATION MONITORING PROGRAM

THIRD PARTY ADMININSTATORS (TPA) TRISTAR - RANCHO (UNIT 1) TRISTAR - RANCHO (UNIT 1) TRISTAR - SANTA ANA (UNIT 2) TRISTAR - SANTA ANA (UNIT 2) INTERCARE (UNIT 3) INTERCARE (UNIT 3) AIMS (UNIT 4) AIMS (UNIT 4)

WORKERS’ COMPENSATION MONITORS ALEX ROSSI County Contract Administrator TONY TARAS CPS – Workers’ Compensation ROSE BLOOM Supervising QAE – Units 1 and 2 TONI VU QAE – Tristar Unit 1 MARK LEBLANC QAE – Tristar Unit 2 JOE CARRILLO Supervising QAE – Units 3 and 4 PAM KENNEDY QAE – Intercare Unit 3 ERNIE ROMO QAE – AIMS Unit 4 CHRIS HURREY QAE – AIMS Unit 4

“The Quality Assurance Evaluator is a County employee designated as an agent for the County responsible for monitoring the Contractor’s performance, approving over limit payments, advising and training third party administrator staff in County payroll systems and other County procedures. At times this employee may be referred to as ‘County Monitor’.”

DUTIES OF THE COUNTY MONITOR Review all delayed claims at 30/60/90 day intervals Review all delayed claims at 30/60/90 day intervals Approve all litigation referrals to County Counsel Approve all litigation referrals to County Counsel Approve all award payments Approve all award payments Approve all payments over $7, Approve all payments over $7, Provide training to TPA staff Provide training to TPA staff

DUTIES OF THE COUNTY MONITOR Assist TPA staff on balancing of complex cases Assist TPA staff on balancing of complex cases Analyze claims and provide settlement recommendations and authority Analyze claims and provide settlement recommendations and authority Address questions and concerns of injured workers, County departments, and defense attorneys Address questions and concerns of injured workers, County departments, and defense attorneys Attend claim reviews Attend claim reviews Conduct annual audit of the TPA’s Conduct annual audit of the TPA’s

LIAISON BETWEEN DEPARTMENTS AND THIRD PARTY ADMINISTRATORS

CLAIM REVIEWS Reviews should be held at least quarterly with County Monitors, CEO RTW personnel, Departmental RTW personnel, Loss Control, and County Counsel. Reviews should be held at least quarterly with County Monitors, CEO RTW personnel, Departmental RTW personnel, Loss Control, and County Counsel. Don’t overload! If necessary, schedule more frequent claim reviews. Don’t overload! If necessary, schedule more frequent claim reviews.

CLAIM REVIEWS File Selection: Choose files with complex claims or RTW issues. Choose files with complex claims or RTW issues. Get input from your TPA’s, County Monitors, and Counsel. Get input from your TPA’s, County Monitors, and Counsel. “Out of service” does not mean “out of sight, out of mind”! “Out of service” does not mean “out of sight, out of mind”!

CLAIM REVIEWS What we need from you: What we need from you: Information about any RTW efforts that have been made Information about any RTW efforts that have been made Information about any disciplinary action being taken against the injured worker (unless confidential) Information about any disciplinary action being taken against the injured worker (unless confidential) Information about any other action the injured worker is taking against the County (unless confidential) Information about any other action the injured worker is taking against the County (unless confidential) Type of retirement plan Type of retirement plan Out of service date and termination reason, if any Out of service date and termination reason, if any

ANNUAL TPA AUDITS We randomly select 80 files to audit TPA performance during a defined period. We randomly select 80 files to audit TPA performance during a defined period. TPA’s are scored on 37 questions assigned weights based on level of importance. TPA’s are scored on 37 questions assigned weights based on level of importance. A total score is calculated based on the weighted scores in each category. A total score is calculated based on the weighted scores in each category. There are “mutually beneficial performance and financial incentives” applied based on the total score. There are “mutually beneficial performance and financial incentives” applied based on the total score.

ANNUAL TPA AUDITS CHANGES IN 2009: CHANGES IN 2009: Vocational rehabilitation questions have been eliminated Vocational rehabilitation questions have been eliminated New questions on: New questions on:  State Panel QME Process  Supplemental Job Displacement  Work Restriction Letters

WORK RESTRICTION LETTERS

QUESTIONS?