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WORKERS’ COMPENSATION MONITORING PROGRAM TONY TARAS (800) 782-5888 ext 1678

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Presentation on theme: "WORKERS’ COMPENSATION MONITORING PROGRAM TONY TARAS (800) 782-5888 ext 1678"— Presentation transcript:

1 WORKERS’ COMPENSATION MONITORING PROGRAM TONY TARAS (800) 782-5888 ext 1678 ataras@ceo.lacounty.gov ataras@ceo.lacounty.gov

2 County Code 5.31.050 Workers’ Compensation System 1. Report, investigate, and adjust claims. 2. Determine compensability and pay benefits. 3. Collect and report statistical data. 4. Establish and review reserves. 5. “Control…workers’ compensation costs consistent with full provision of benefits under the law.”

3 TPA CONTRACTS – TECHNICAL EXHIBIT I WORKERS’ COMPENSATION PROGRAM “The primary objective of this program is to provide all workers’ compensation benefits required under State law to injured County employees on a timely basis, at the least possible cost to the County.”

4 TRISTAR – RANCHO (UNIT 1) MANAGER: KAREN SATURDAY (800) 782-5888 ext 1683 (800) 782-5888 ext 1683 karen.saturday@tristargroup.net karen.saturday@tristargroup.netkaren.saturday@tristargroup.net MONITORS: MARK LEBLANC (800) 782-5888 ext 1648 (800) 782-5888 ext 1648 mleblanc@ceo.lacounty.gov mleblanc@ceo.lacounty.gov@ceo.lacounty.gov TONI VU TONI VU (800) 782-5888 ext 1769 (800) 782-5888 ext 1769 tvu@ceo.lacounty.gov tvu@ceo.lacounty.govtvu@ceo.lacounty.gov

5 TRISTAR – RANCHO (UNIT 2) MANAGER: OLA OLIFESO (800) 782-5888 ext 1152 (800) 782-5888 ext 1152 ola.olifeso@tristargroup.net ola.olifeso@tristargroup.net@tristargroup.net MONITOR: ROSE BLOOM (800) 782-5888 ext 1676 (800) 782-5888 ext 1676 rbloom@ceo.lacounty.gov rbloom@ceo.lacounty.gov

6 INTERCARE (UNIT 3) MANAGER: KATHLEEN BURRIS (866) 221-2968 ext 430 (866) 221-2968 ext 430 kburris@intercareins.com kburris@intercareins.comkburris@intercareins.com MONITORS: JOE CARRILLO (866) 221-2968 ext 422 (866) 221-2968 ext 422 jcarrillo@ceo.lacounty.gov jcarrillo@ceo.lacounty.govjcarrillo@ceo.lacounty.gov PAM KENNEDY PAM KENNEDY (866) 221-2968 ext 421 (866) 221-2968 ext 421 pkennedy@ceo.lacounty.gov pkennedy@ceo.lacounty.govpkennedy@ceo.lacounty.gov

7 AIMS (UNIT 4) MANAGER: CHERYL AGEE (661) 705-2908 (661) 705-2908 cagee@aims4claims.com cagee@aims4claims.comcagee@aims4claims.com MONITOR: ERNIE ROMO (661) 705-2905 (661) 705-2905 eromo@ceo.lacounty.gov eromo@ceo.lacounty.goveromo@ceo.lacounty.gov

8 “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’.”

9 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 $7,500.00 Approve all payments over $7,500.00 Provide training to TPA staff Provide training to TPA staff

10 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

11 LIAISON BETWEEN DEPARTMENTS AND THIRD PARTY ADMINISTRATORS

12 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.

13 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”!

14 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

15 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.

16 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

17 WORK RESTRICTION LETTERS

18 QUESTIONS?

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