Florida Division Of Workers Compensation Employee Assistance and Ombudsman Office FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief.

Florida Division Of Workers’ Florida Division Of Workers’ CompensationCompensation

Employee Assistance Employee Assistance and Ombudsman and Ombudsman

OfficeOffice FWCI Annual ConferenceFWCI Annual Conference

August 24, 2005August 24, 2005

Roy O. WoodRoy O. Wood

Bureau ChiefBureau Chief

Employee Assistance and Employee Assistance and Ombudsman OfficeOmbudsman Office

Effectuate the “self-executing” Effectuate the “self-executing” features of the workers’ features of the workers’

compensation system without compensation system without undue expense, costly undue expense, costly

litigation or delay in the litigation or delay in the provision of benefits.provision of benefits.

Core Functions of EAOCore Functions of EAOOutreach and EducationOutreach and Education

Call Center/Request for Call Center/Request for Assistance Assistance

Early Intervention ProgramEarly Intervention Program

Ombudsman Ombudsman

InvestigationsInvestigations

OutreachOutreach

Heighten awareness Add value through contact

Benefits to all stakeholders

EducationEducation

EmployersEmployers

Injured WorkersInjured Workers

CarriersCarriers

Call Center/Request for Call Center/Request for AssistanceAssistance

Centralized Access PointCentralized Access Point

Dedicated telephone and web-based Dedicated telephone and web-based centercenter

Staffed by professionals who will beStaffed by professionals who will be able to answer questions for allable to answer questions for all stakeholdersstakeholders

Division of Workers’ Division of Workers’ Compensation research Compensation research suggests that in the past suggests that in the past

15 years over 60% of 15 years over 60% of benefit costs were benefit costs were

incurred by 10% of claimsincurred by 10% of claims

Early Intervention Early Intervention ProgramProgram

Identification of potentially Identification of potentially high exposure claims through high exposure claims through the use of technologythe use of technology

Proactively contact injured Proactively contact injured worker to maximize return to worker to maximize return to workwork

OmbudsmanOmbudsman Advocate to foster Advocate to foster

communication betweencommunication between

employer, adjuster andemployer, adjuster and

injured workersinjured workers Will explain benefits to injured Will explain benefits to injured

workers workers Will reduce load on adjusterWill reduce load on adjuster

InvestigationsInvestigations

In the case of an impasse, or In the case of an impasse, or unclear facts, a case may be unclear facts, a case may be referred to an investigatorreferred to an investigator

Objective pursuit of the factsObjective pursuit of the facts Exercise authority provided Exercise authority provided

under 440.20(9) F.S.under 440.20(9) F.S. Facilitate dispute resolutionFacilitate dispute resolution

EAOEAO

EAO vision facilitating the EAO vision facilitating the self-execution of the WC lawself-execution of the WC law

Legislatively mandated to Legislatively mandated to assist the injured workerassist the injured worker

EAO must wear several hatsEAO must wear several hats

EAOEAO

EAO strives to be a EAO strives to be a professional front-line professional front-line participant in the WC participant in the WC system adding value system adding value through its involvement through its involvement

Thank you!Thank you!

Workers’ Compensation Workers’ Compensation Claims 69L-3, F.A.C.Claims 69L-3, F.A.C.

Fred Becknell Fred Becknell

Insurance Administrator Insurance Administrator

Bureau of Monitoring & AuditBureau of Monitoring & Audit

Workers’ Compensation Workers’ Compensation Claims Claims 69L-3, F.A.C. 69L-3, F.A.C.

226 days have passed 226 days have passed since the Rule since the Rule became effective on became effective on January 10January 10thth..

136 days have passed 136 days have passed since the Forms since the Forms became mandatory became mandatory on April 10on April 10thth..

A few observations in A few observations in regard to the timely regard to the timely filing and accuracy of filing and accuracy of Workers’ Compensation Workers’ Compensation claim forms.claim forms.

DWC-1 / First Report of Injury or DWC-1 / First Report of Injury or IllnessIllness

DWC-4 / Notice of Action/ChangeDWC-4 / Notice of Action/Change

DWC-12 / Notice of DenialDWC-12 / Notice of Denial

DWC-13 / Claim Cost ReportDWC-13 / Claim Cost Report

Required Fields / All Forms Required Fields / All Forms

69L-3.003(3)69L-3.003(3)

Employee’s name (First, middle, last)Employee’s name (First, middle, last)

Employee’s social security number *Employee’s social security number *

Month, day and year of the accident Month, day and year of the accident (mm-dd-yy or mm-dd-ccyy)(mm-dd-yy or mm-dd-ccyy)

Sent to Division DateSent to Division Date

* Or Division Assigned Number (DAN)* Or Division Assigned Number (DAN)

Reporting of the Social Security Reporting of the Social Security Number 69L-3.003(3)(a)Number 69L-3.003(3)(a)

Report the actual Social Security Number as Report the actual Social Security Number as assigned by the Social Security assigned by the Social Security Administration.Administration.

If unknown or the employee does not have If unknown or the employee does not have one, the claims-handling entity shall contact one, the claims-handling entity shall contact the Division by means of the Division’s the Division by means of the Division’s website:website:

www.fldfs.com/WC/organization/odqc.htmlwww.fldfs.com/WC/organization/odqc.html

Follow the directions (under Records Follow the directions (under Records Management - Division Assigned Numbers).Management - Division Assigned Numbers).

Required Fields on all Required Fields on all Forms 69L-3.003(3)Forms 69L-3.003(3)

Insurer Code # & Insurer NameInsurer Code # & Insurer Name

Service Co/TPA Code # *Service Co/TPA Code # *

Claims-handling Entity File #Claims-handling Entity File #

Claims-handling Entity’s Name, Claims-handling Entity’s Name, Address & Telephone Address & Telephone

* If applicable* If applicable

Insurer ID# ? Insurer ID# ?

What is my Insurer ID#?What is my Insurer ID#?

Division’s web-site: Division’s web-site: www.fldfs.com/wcwww.fldfs.com/wc Select the Select the “Databases” option.“Databases” option.

Select “Insurer/Claim Select “Insurer/Claim Administrator Database”.Administrator Database”.

Type in the company name Type in the company name and hit the “Submit and hit the “Submit Query” key.Query” key.

InsuranceInsurance

The Company Name, Insurer ID The Company Name, Insurer ID # & Corresponding Information # & Corresponding Information is Displayed.is Displayed.

Filing of WC Forms Filing of WC Forms 69L-3.003(5) 69L-3.003(5)

All submissions of forms All submissions of forms filed with the Division filed with the Division shall conform with the shall conform with the promulgated form in promulgated form in design, layout, field size design, layout, field size and content (data and content (data elements).elements).

DFS-F2-DWC-1 / 69L-3.0045DFS-F2-DWC-1 / 69L-3.0045First Report of Injury or IllnessFirst Report of Injury or Illness

Major changes for discussionMajor changes for discussion

1.1. Reporting of the Claims-handling Reporting of the Claims-handling Entity Information Entity Information

2.2. Reporting of Indemnity Only Reporting of Indemnity Only Denied CasesDenied Cases

3.3. Reporting of Delayed Disability Reporting of Delayed Disability CasesCases

4.4. Reporting of Lost Time CasesReporting of Lost Time Cases5.5. Reporting of Penalties & Interest Reporting of Penalties & Interest

Paid to the EmployeePaid to the Employee

Claims-Handling Entity Information Claims-Handling Entity Information 69L-3.0045(1)(d)69L-3.0045(1)(d)

““Indemnity Only Denied Indemnity Only Denied Cases” 69L-3.0045 (1)(d)5.b Cases” 69L-3.0045 (1)(d)5.b

and (2)(g)and (2)(g)Report cases where only the Report cases where only the indemnity benefits are denied indemnity benefits are denied (medical benefits being provided).(medical benefits being provided).

Box 1(b) “Indemnity Only Denied Box 1(b) “Indemnity Only Denied Case” is to be marked. Forms Case” is to be marked. Forms DWC-1 and DWC-12 are to be filed DWC-1 and DWC-12 are to be filed with the Division at the same time. with the Division at the same time.

Reporting of Delayed Reporting of Delayed Disability Cases 69L-Disability Cases 69L-

3.0045(2)(b)3.0045(2)(b)When disability is When disability is not not immediate andimmediate and continuouscontinuous but but result in 8 or more days of result in 8 or more days of disability - send a completed disability - send a completed DWC-1 within 6 days after DWC-1 within 6 days after knowledge of the 8knowledge of the 8thth day of day of disability. disability.

Delayed Disability Case Delayed Disability Case 69L-3.0045(1)(d) 5. c. i.69L-3.0045(1)(d) 5. c. i.

Reporting vs. Paying Reporting vs. Paying Delayed Disability CasesDelayed Disability Cases

Important ReminderImportant Reminder: Do not : Do not confuse the filing of the DWC-1 confuse the filing of the DWC-1 with the timely payment of with the timely payment of indemnity benefits pursuant to indemnity benefits pursuant to s.440.20(2)(a), F.S. s.440.20(2)(a), F.S.

PaymentPayment is due on the 6 is due on the 6thth day after the 8day after the 8thth day of day of disability.disability.

FilingFiling is due within 6 days is due within 6 days after the knowledge of the after the knowledge of the 88thth day of disability. day of disability.

Reporting of Lost Time Reporting of Lost Time Cases 69L-3.0045(2)(a)Cases 69L-3.0045(2)(a)

When disability is When disability is immediate immediate and continuousand continuous for 8 or more for 8 or more days, send a completed DWC-1 days, send a completed DWC-1 within 14 days after within 14 days after knowledge of the injury or knowledge of the injury or illness.illness.

Reporting of Lost Time Reporting of Lost Time Cases 69L-3.0045(2)(a)Cases 69L-3.0045(2)(a)

1.1. Initial lost time casesInitial lost time cases

2.2. Full salary cases (employer Full salary cases (employer paid for 8 or more days)paid for 8 or more days)

3.3. Death cases with/without Death cases with/without dependentsdependents

4.4. VolunteersVolunteers

Lost Time Case – Required Fields Lost Time Case – Required Fields 69L-3.0045(1)(d) 5.d. 69L-3.0045(1)(d) 5.d.

Reporting of Lost Time Reporting of Lost Time CasesCases

69L-3.0045(2)(c) – TP 69L-3.0045(2)(c) – TP Benefits 69L-Benefits 69L-3.0045(2)(d) – IBs 3.0045(2)(d) – IBs 69L-3.0045(2)(e) - 69L-3.0045(2)(e) - SettlementsSettlements

If the initial payment of indemnity If the initial payment of indemnity benefits is for TP, IB or results from benefits is for TP, IB or results from an agreement or order for an agreement or order for indemnity benefits send the indemnity benefits send the completed DWC-1 within 14 days completed DWC-1 within 14 days after the date payment mailed.after the date payment mailed.

Reporting of Penalties & Reporting of Penalties & Interest 69L-3.0045(1)(f)Interest 69L-3.0045(1)(f)

DWC-4 Notice of Action/Change DWC-4 Notice of Action/Change 69L-3.0091 69L-3.0091

File with the Division within 14 File with the Division within 14 days of the knowledge of the days of the knowledge of the action or change which is being action or change which is being reporting for reporting for lost time caseslost time cases..

Copies of the Form are to be Copies of the Form are to be mailed to the employee and mailed to the employee and employer at the same time.employer at the same time.

Incomplete DWC-4sIncomplete DWC-4s 69L-3.0091 69L-3.0091

The filing of the form with The filing of the form with only the “Remarks Section” only the “Remarks Section” completed will not constitute completed will not constitute filing of the required filing of the required information - applicable information - applicable field(s) are left blank.field(s) are left blank.

Suspensions of Benefits Suspensions of Benefits 69L-3.0091(2) 69L-3.0091(2)

State the “Effective Date” (the State the “Effective Date” (the last date through which benefits last date through which benefits were paid) of the suspension were paid) of the suspension and the applicable suspension and the applicable suspension “Reason Code”.“Reason Code”.

69L-3.009169L-3.0091(3) (3) ReinstatementsReinstatements

Upon the reinstatement of Upon the reinstatement of indemnity benefits after a indemnity benefits after a suspension, report the suspension, report the effective date of the effective date of the “Indemnity Reinstated After “Indemnity Reinstated After Suspension” & the “Disability Suspension” & the “Disability Type” of benefits being Type” of benefits being reinstated.reinstated.

69L-3.009169L-3.0091(4) (4) Return To Work Return To Work

Report when the employee hasReport when the employee has

been medically released to RTW,been medically released to RTW, the assignment of physical the assignment of physical

restrictions,restrictions, the removal of all physical the removal of all physical

restrictions, restrictions, the actual RTW.the actual RTW.

69L-3.009169L-3.0091(5) (5) SettlementsSettlements

Report the “Date Payment Report the “Date Payment Mailed” resulting from a final Mailed” resulting from a final order of indemnity benefits order of indemnity benefits pursuant to s. 440.20(11), F.S. pursuant to s. 440.20(11), F.S.

* This date can not be reported * This date can not be reported as earlier than the date the as earlier than the date the settlement was actually approved.settlement was actually approved.

DWC-12 Notice of Denial DWC-12 Notice of Denial 69L-3.012(1) 69L-3.012(1)

Copies of the DWC-12 are to be Copies of the DWC-12 are to be mailed to the employee, mailed to the employee, employer and any additional employer and any additional party requesting payment or party requesting payment or authorization, within 14 days of authorization, within 14 days of the date the decision to the date the decision to deny or rescind the denial.deny or rescind the denial.

Denial of Compensability Denial of Compensability 69L-3.012(2) 69L-3.012(2)

When denying the When denying the compensability of or coverage compensability of or coverage for a case, send the DWC-12 to for a case, send the DWC-12 to the Division within 14 days after the Division within 14 days after notification of the injury, illness notification of the injury, illness or death with a completed DWC-or death with a completed DWC-1.1.

Denial of Indemnity Only Denial of Indemnity Only 69L-3.012(3) 69L-3.012(3)

When denying only the When denying only the indemnity benefits of a claim indemnity benefits of a claim send the DWC-12 to the send the DWC-12 to the Division within 14 days after Division within 14 days after notification of the injury, illness notification of the injury, illness or death with a completed or death with a completed DWC-1.DWC-1.

Denial of Subsequent Denial of Subsequent Indemnity 69L-3.012(4)Indemnity 69L-3.012(4)

When denying When denying any any subsequent indemnity subsequent indemnity benefitbenefit on a lost time case on a lost time case send Form DWC-12 within 14 send Form DWC-12 within 14 days of the knowledge of the days of the knowledge of the requested benefit being requested benefit being denied.denied.

Petition for Benefits Petition for Benefits 69L-3.012(5) 69L-3.012(5)

If a Petition for Benefits (PFB) is If a Petition for Benefits (PFB) is the first notification of an injury the first notification of an injury and you are denying the case in and you are denying the case in its entirety (or only the indemnity its entirety (or only the indemnity portion), send Forms DWC-12 and portion), send Forms DWC-12 and DWC-1 to the Division within 14 DWC-1 to the Division within 14 days of the receipt of the PFB.days of the receipt of the PFB.

Rescinded Denial Rescinded Denial 69L-3.012(6) 69L-3.012(6)

When rescinding the denial of When rescinding the denial of previously denied indemnity previously denied indemnity benefits send Form DWC-12 with benefits send Form DWC-12 with the “Denial Rescinded Section” the “Denial Rescinded Section” completed within 14 days of the completed within 14 days of the date that the denial was rescinded.date that the denial was rescinded.

DWC-13 Claims Cost Report DWC-13 Claims Cost Report 69L-3.016 69L-3.016

Initial ReportInitial Report – file within – file within 30 days after30 days after the 6the 6thth month anniversary of the date month anniversary of the date of accident – no early filings accepted – of accident – no early filings accepted – unless filing as the final report.unless filing as the final report.

Annual ReportsAnnual Reports – file within – file within 30 days 30 days afterafter the annual anniversary of the the annual anniversary of the date of accident – no early filings date of accident – no early filings accepted – unless filing as the final accepted – unless filing as the final report.report.

Workers’ Compensation Claim Workers’ Compensation Claim Forms Forms

69L-3.025(3)69L-3.025(3)All forms filed on or after All forms filed on or after April 10April 10thth, 2005 must be , 2005 must be the 08/2004 version the 08/2004 version (regardless of the date of (regardless of the date of injury).injury).

Coming Spring ‘06Coming Spring ‘06Update of 69L-3 / DWC-1Update of 69L-3 / DWC-1

Optional reporting of the SIC Code Optional reporting of the SIC Code until October 2006 in lieu of the until October 2006 in lieu of the NAICS Code.NAICS Code.

Required reporting of the employer’s Required reporting of the employer’s knowledge of the injury or illness.knowledge of the injury or illness.

Required reporting of the NAICS Required reporting of the NAICS (SIC) Code and the NCCI Code on the (SIC) Code and the NCCI Code on the DWC-1.DWC-1.

Coming Spring ‘06Coming Spring ‘06Update of 69L-3 / DWC-Update of 69L-3 / DWC-

1313

The reporting of previous paid The reporting of previous paid indemnity and medical for acquired indemnity and medical for acquired claims can be reported in an claims can be reported in an “Acquired” or “Unallocated” “Acquired” or “Unallocated” format. All reporting will include format. All reporting will include the claim cost amounts for each the claim cost amounts for each applicable indemnity and medical in applicable indemnity and medical in addition to the acquired amounts. addition to the acquired amounts.

DWC-e-Alert Program DWC-e-Alert Program

Great way to keep current with Great way to keep current with updates from the Division.updates from the Division.

Sign up for the DWC e-Alert Sign up for the DWC e-Alert program for the quickest program for the quickest notification of rule making & notification of rule making & other DWC activities. Located other DWC activities. Located on the Division’s Website.on the Division’s Website.

www.fldfs.com/wc/www.fldfs.com/wc/

Fred Becknell - Insurance Fred Becknell - Insurance AdministratorAdministrator

E-mail: E-mail: [email protected]@FLDFS.com

850-413-1763850-413-1763

Division of Workers’ Division of Workers’ CompensationCompensation

Office of Data Quality & Office of Data Quality & CollectionCollection

Don DavisDon DavisSenior Manager Analyst Senior Manager Analyst

SupervisorSupervisorData Quality & CollectionData Quality & Collection

(850) 413-1711(850) [email protected]@fldfs.com

How to Avoid Form Rejection and Penalty How to Avoid Form Rejection and Penalty ExposureExposure

Data Quality – Procedures for Data Quality – Procedures for Filing DocumentsFiling Documents

W.C. Claims Rule 69L-3.003 (1) effective January W.C. Claims Rule 69L-3.003 (1) effective January 10, 200510, 2005

• The Division shall return to the claims-handling The Division shall return to the claims-handling entity any document on which the appropriate entity any document on which the appropriate information required in subsection (3) of this information required in subsection (3) of this section and paragraph 69L-3.0045(1)(d) F.A.C. section and paragraph 69L-3.0045(1)(d) F.A.C. does not appear, and will notify the claims-does not appear, and will notify the claims-handling entity of its error or omission.handling entity of its error or omission.

• The document will be considered completed and The document will be considered completed and in compliance when the corrected document is in compliance when the corrected document is resent to the Division.resent to the Division.

Document Returned by Document Returned by DivisionDivisionDue to Non-compliance with Rule 69L-Due to Non-compliance with Rule 69L-3.0033.003

Reviewer: ______________ Date: Reviewer: ______________ Date: ________________________

• Effective April 11, 2005, the Division Effective April 11, 2005, the Division began enforcing the submission of began enforcing the submission of required data fields for DWC forms required data fields for DWC forms pursuant to the WC Claims Rule, 69L-pursuant to the WC Claims Rule, 69L-3.003(1), F.A.C. 3.003(1), F.A.C.

Indemnity Claim FormsIndemnity Claim Forms(DWC-1, DWC-4, DWC-12, DWC-13)(DWC-1, DWC-4, DWC-12, DWC-13)

Example for Paper Filed Example for Paper Filed FormsForms

Top Reasons for Rejecting the Top Reasons for Rejecting the Paper Filed First Report of Paper Filed First Report of

Injury/Illness (DWC-1)Injury/Illness (DWC-1)

#1#1

#1 – “Sent to Division Date” #1 – “Sent to Division Date” is Missingis Missing

#2 – Claims Handling Information is #2 – Claims Handling Information is IncompleteIncomplete

#2#2



#3 – Injury/Illness that Occurred #3 – Injury/Illness that Occurred is Missingis Missing

#3#3



#4#4

#4 – Insurer Name and/or Insurer Code #4 – Insurer Name and/or Insurer Code Number are MissingNumber are Missing

#4#4



Top Reasons for Rejecting the Top Reasons for Rejecting the Paper Filed Claim Cost Report Paper Filed Claim Cost Report

(DWC-13)(DWC-13)

#1#1

#1 – Weeks/days missing for indemnity when $ #1 – Weeks/days missing for indemnity when $ amount is givenamount is given

#2 – Insurer Name and/or Insurer Code #2 – Insurer Name and/or Insurer Code Number are MissingNumber are Missing

#2#2#2#2


(DWC-13)(DWC-13)

#3#3

#3 – Settlement Dates are #3 – Settlement Dates are MissingMissing

#3#3


(DWC-13)(DWC-13)

#4#4

#4 – AWW / Comp Rate #4 – AWW / Comp Rate MissingMissing


(DWC-13)(DWC-13)

QuestionQuestion – What percentage of all – What percentage of all returned DWC-1’s and DWC-13’s returned DWC-1’s and DWC-13’s are rejected for these preceding are rejected for these preceding

“top 4” data fields?“top 4” data fields?

A.A. 25 – 49%25 – 49%

B.B. 50 – 75% 50 – 75%

C.C. 76 – 100%76 – 100%

Answer : B – 75%Answer : B – 75%

Legislative Mandate to Review Legislative Mandate to Review All Medical Bills (DWC-9, 10, 11, All Medical Bills (DWC-9, 10, 11,

90) 90) Section 440.20(2)(b), F.S.Section 440.20(2)(b), F.S.

The division is now required to review The division is now required to review 100 percent of all submitted medical 100 percent of all submitted medical bills to evaluate insurer performance. bills to evaluate insurer performance.

Last fiscal year, over four million Last fiscal year, over four million medical bills were electronically medical bills were electronically reviewed in order to assess timely reviewed in order to assess timely insurer performance standards insurer performance standards pursuant to s.440.20(6)(b), F.S.pursuant to s.440.20(6)(b), F.S.

Florida Workers’ Compensation Florida Workers’ Compensation Medical Services, Billing, Filing Medical Services, Billing, Filing and Reporting Rule and Reporting Rule (69L-7.602 (69L-7.602

F.A.C.)F.A.C.)

Effective Date: July 4, 2004Effective Date: July 4, 2004

Projected Amended Effective Projected Amended Effective Date: Date:

Mid-September 2005Mid-September 2005

Requirements for Medical BillRequirements for Medical BillCompletion and Filing Completion and Filing

(DWC-9, 10, 11, 90) (DWC-9, 10, 11, 90)

Important Highlights for Important Highlights for Insurer ResponsibilitiesInsurer Responsibilities

Medical claim bills are required to be Medical claim bills are required to be filed with the Division for filed with the Division for “ALL MEDICAL “ALL MEDICAL ONLY AND LOST TIME CASES”.ONLY AND LOST TIME CASES”.

Insurer must pay, adjust and pay, Insurer must pay, adjust and pay, disallow or deny bill within 45 calendar disallow or deny bill within 45 calendar days from date received [s.440.20(2)days from date received [s.440.20(2)(b)](b)]

Important Highlights for Important Highlights for Insurer ResponsibilitiesInsurer Responsibilities

Insurer must correct and re-file all Insurer must correct and re-file all rejected medical bills within the 45-rejected medical bills within the 45-day filing timeline.day filing timeline.

Once the medical bill records are Once the medical bill records are uploaded to our system, an uploaded to our system, an electronic confirmation report is electronic confirmation report is immediately issued to the EDI immediately issued to the EDI submitter that details the submitter that details the acceptance or rejection of each acceptance or rejection of each record submitted.record submitted.

Rejected Medical Bills (DWC-9, 10, Rejected Medical Bills (DWC-9, 10, 11 & 90) can lead to penalties if 11 & 90) can lead to penalties if

not properly corrected and timely not properly corrected and timely resubmitted to the division.resubmitted to the division.

CAUTION!CAUTION!

Top 4 Data Elements Top 4 Data Elements Causing Rejection of DWC-9Causing Rejection of DWC-9

#1#1

#1 – Federal Employer #1 – Federal Employer Identification Number (FEIN) Identification Number (FEIN) provided by the EDI Submitter provided by the EDI Submitter does not match Division Records does not match Division Records

EDI Medical Record EDI Medical Record LayoutLayout

#2 – EOBR #2 – EOBR Codes used Codes used incorrectlyincorrectly

#2#2

#4 – No Matching Code #4 – No Matching Code Value from AMA CPT or Value from AMA CPT or ICD ManualsICD Manuals

#4#4

#3#3 #3 – Blank or Zero Values #3 – Blank or Zero Values submitted in the EDI Record submitted in the EDI Record LayoutLayout

#3#3

EDI Medical Record EDI Medical Record LayoutLayout

Top 4 Data Elements Top 4 Data Elements Causing Rejection of DWC-9Causing Rejection of DWC-9

The Industry The Industry Has Has

Significantly Significantly Improved!Improved!

Rejected Medical BillsRejected Medical Bills

For calendar year 2003, over For calendar year 2003, over 43,00043,000 medical bills were rejected medical bills were rejected by the division for quality issues, by the division for quality issues, and never corrected and and never corrected and resubmitted.resubmitted.

For calendar year 2004, over For calendar year 2004, over 31,00031,000 medical bills were rejected medical bills were rejected by the division for quality issues, by the division for quality issues, and never corrected and and never corrected and resubmitted.resubmitted.

For the first six months of For the first six months of calendar year 2005, only calendar year 2005, only 2,2942,294 medical bills were rejected by medical bills were rejected by the division for quality issues, the division for quality issues, and not corrected and and not corrected and resubmitted to the division.resubmitted to the division.

Rejected Medical BillsRejected Medical Bills

Division Steps to Help Insurers Division Steps to Help Insurers File Accurately and TimelyFile Accurately and Timely

Contacted all 101 EDI medical Contacted all 101 EDI medical submitters individually to submitters individually to validate and/or correct their validate and/or correct their insurer and FEIN numbers.insurer and FEIN numbers.

Created an educational/training Created an educational/training guide (with the assistance of AHCA) guide (with the assistance of AHCA) on the proper usage of EOBR on the proper usage of EOBR codes, and sent it to all Medical EDI codes, and sent it to all Medical EDI submitters. The guide is also submitters. The guide is also posted on DWC’s website, under posted on DWC’s website, under the “EDI” link.the “EDI” link.

HELP from the Medical EDI HELP from the Medical EDI SystemSystem

Same day notification to Insurers of Same day notification to Insurers of the “Claim Processing Report” the “Claim Processing Report” listing accepted/rejected medical listing accepted/rejected medical bills.bills. Rejected data fields are noted Rejected data fields are noted in in redred for quick and easy for quick and easy identification – real time access identification – real time access

Potential “duplicate” medical bills Potential “duplicate” medical bills are identified in the new system are identified in the new system (MDS), and flagged for correction on(MDS), and flagged for correction on the “Claims Processing Report” – the “Claims Processing Report” – real time accessreal time access

Developed a cumulative Developed a cumulative “Outstanding “Outstanding Rejected Medical Claims” Rejected Medical Claims” report which report which is emailed to submitters twice a is emailed to submitters twice a month. This feedback helps our month. This feedback helps our customers manage rejected medical customers manage rejected medical claims. claims.

Created an Internet Website for direct Created an Internet Website for direct online entry, validation, submission, online entry, validation, submission, correction, and resubmission of correction, and resubmission of medical data. This website went live in medical data. This website went live in January 2005 – realJanuary 2005 – real time access. time access.

HELP from the Medical EDI HELP from the Medical EDI SystemSystem

An Acknowledgement report An Acknowledgement report listing detailed errors is listing detailed errors is returned to Claim Administrators returned to Claim Administrators for every Claims EDI submission.for every Claims EDI submission.

HELP from the Claims EDI HELP from the Claims EDI SystemSystem

Claim Administrators notified Claim Administrators notified if no DWC-1 on file, for an if no DWC-1 on file, for an electronically filed DWC-13.electronically filed DWC-13.

““Report cards” are issued monthly Report cards” are issued monthly to Claim Administrators, which to Claim Administrators, which include the top 5 recurring errors.include the top 5 recurring errors.

HELP from the Claims EDI HELP from the Claims EDI SystemSystem

A cumulative monthly report A cumulative monthly report of Rejected But Not of Rejected But Not Resubmitted DWC-1’s and Resubmitted DWC-1’s and DWC-13’s is also provided.DWC-13’s is also provided.

Suspense of Paper Filed Claim Suspense of Paper Filed Claim Forms when Required Data is Forms when Required Data is

MissingMissing Original “Sent to Division Date”:Original “Sent to Division Date”:

06/15/0506/15/05

Form received at Division (DWC):Form received at Division (DWC):

06/20/0506/20/05

DWC rejection stamp date:DWC rejection stamp date: 06/21/05 06/21/05 (date form is returned to sender)(date form is returned to sender)

Date completed form must be resent to DWC:Date completed form must be resent to DWC:

07/05/0507/05/05 (06/21/05 + (06/21/05 +

14 days)14 days)

New “Sent to Division” date:New “Sent to Division” date: 06/30/05 06/30/05

Data completed Form received at DWC:Data completed Form received at DWC:

07/06/0507/06/05

Original “Sent to Division” date honored by DWC: Original “Sent to Division” date honored by DWC:

06/15/05 06/15/05

Distribute the information for Distribute the information for top reasons for rejection to top reasons for rejection to the appropriate personnel the appropriate personnel responsible for completing the responsible for completing the forms. Conduct training if forms. Conduct training if necessary.necessary.

Recommendation to Reduce Recommendation to Reduce Paper Filed Claim FormsPaper Filed Claim Forms

Recommendations to Reduce Recommendations to Reduce Medical Bill ViolationsMedical Bill Violations

Submit data to the division daily if Submit data to the division daily if possible, or at a minimum of once possible, or at a minimum of once per week.per week.

Require your medical bill review Require your medical bill review vendor to copy you on the bi-vendor to copy you on the bi-monthly “Outstanding Rejected monthly “Outstanding Rejected Medical Claims” report. Use the Medical Claims” report. Use the Centralized Performance System Centralized Performance System (CPS) to “monitor” your medical (CPS) to “monitor” your medical bill rejections.bill rejections.

Encourage your medical bill vendor Encourage your medical bill vendor to build “in-house” edits that match to build “in-house” edits that match the division’s edits and the division’s edits and requirements, and have the vendor requirements, and have the vendor edit your medical filings prior to edit your medical filings prior to submission to the division.submission to the division.

Contact the Office of Data Contact the Office of Data Quality and Collection for a Quality and Collection for a customized report that customized report that identifies the top reasons identifies the top reasons your medical bills are your medical bills are rejecting.rejecting.

Recommendations to Reduce Recommendations to Reduce Medical Bill ViolationsMedical Bill Violations

Thank you!Thank you!

Division of Workers’ Division of Workers’

CompensationCompensation Update on Update on

Proof Of Proof Of Coverage Coverage

and and Claims Claims

EDIEDILinda Yon, EDI Linda Yon, EDI Coordinator E-mail: Coordinator E-mail: [email protected] [email protected] Phone: 850-413-1702Phone: 850-413-1702

Rule Chapter 69L-Rule Chapter 69L-56 56 Florida Florida

Administrative Code Administrative Code is is the EDI Rule for the EDI Rule for Proof of Coverage and Proof of Coverage and Claims (non-medical)Claims (non-medical)

A copy is available on A copy is available on DWC’s website at DWC’s website at

www.fldfs.com/wc/www.fldfs.com/wc/

www.fldfs.comwww.fldfs.com/wc//wc/

Overview of changes to Overview of changes to 69L-56 effective 5-69L-56 effective 5-

29-0529-05 Revised all EDI Trading Revised all EDI Trading Partner Forms Partner Forms For Proof of Coverage - For Proof of Coverage -

adopted the IAIABC adopted the IAIABC Release 2 Proof of Release 2 Proof of Coverage Implementation Coverage Implementation Guide, and a revised FL Guide, and a revised FL POC EDI Implementation POC EDI Implementation ManualManual

Transferred Proof of Transferred Proof of Coverage Coverage cancellation/non-renewal cancellation/non-renewal requirements and filing requirements and filing requirements from 69L-requirements from 69L-6.008 and 69L-6.014 to 6.008 and 69L-6.014 to 69L-56.69L-56.

Overview of changes to 69L-56 Overview of changes to 69L-56 effective 5-29-05effective 5-29-05

As of June 1, 2005, EDI As of June 1, 2005, EDI transactions must be sent as transactions must be sent as

follows:follows:

POC EDI: via Secure Socket POC EDI: via Secure Socket Layer/File Transfer Protocol Layer/File Transfer Protocol (SSL/FTP)(SSL/FTP)

Claims EDI: via SSL/FTP or the Claims EDI: via SSL/FTP or the Advantis Value Added Network Advantis Value Added Network (VAN).(VAN).

Overview of changes to Overview of changes to 69L-56 effective 5-29-0569L-56 effective 5-29-05

Overview of changes to 69L-Overview of changes to 69L-56 effective 5-29-0556 effective 5-29-05

An insurer may contract with a An insurer may contract with a third party vendor, third party vendor, or use a or use a third party vendor’s software third party vendor’s software for electronically sending for electronically sending transactions to the Division, transactions to the Division, but the insurer will still remain but the insurer will still remain responsible for the timely responsible for the timely filing of EDI transactions.filing of EDI transactions.

Overview of changes to Overview of changes to 69L-5669L-56

The “Electronic Supplement to The “Electronic Supplement to the First Report Of Injury” (8the First Report Of Injury” (8thth Day of Disability) requirement Day of Disability) requirement was effective 5-29-05.was effective 5-29-05.

It will remain in place, through It will remain in place, through the date the insurer begins the date the insurer begins submitting via EDI in the new submitting via EDI in the new IAIABC Release 3 format. IAIABC Release 3 format.

Overview of changes to Overview of changes to 69L-5669L-56

After the insurer is After the insurer is submitting data in the R3 submitting data in the R3 format, the Supplement to format, the Supplement to the First Report format will the First Report format will no longer be required. no longer be required.

Future EDI Claims Filing Future EDI Claims Filing Requirement for ALL Requirement for ALL

InsurersInsurers

The The requirementrequirement to to implement Claims EDI will implement Claims EDI will begin with the electronic form begin with the electronic form equivalent of: equivalent of: First Report of Injury or First Report of Injury or

Illness Illness (DWC-1)(DWC-1) Claim Cost Report (DWC-Claim Cost Report (DWC-

13)13)

Claims EDI Filing Claims EDI Filing RequirementRequirement

Proposed EDI Claims Proposed EDI Claims Implementation Requirement:Implementation Requirement:

The Division will divide The Division will divide insurers/self-insurers into three insurers/self-insurers into three

implementation groups, based on implementation groups, based on insurer code number.insurer code number.

Lowest one third in the Lowest one third in the series, and series, and current Release current Release 1 Trading Partners 1 Trading Partners will will implement first.implement first. Middle one third in Middle one third in the the series will series will implement next.implement next. Highest one third Highest one third in the in the series will series will implement last.implement last.

The first group is to begin testing 9 The first group is to begin testing 9 months after the effective date of the months after the effective date of the

rule, and must be in production no later rule, and must be in production no later than 1 quarter after the testing period than 1 quarter after the testing period

begins.begins.

Sample Claims EDI Implementation Sample Claims EDI Implementation ScheduleSchedule

Example: If Effective Date of Rule: Example: If Effective Date of Rule: 4-1-20064-1-2006First Group Must Begin Testing: First Group Must Begin Testing: 1-1-20071-1-2007First Group Must Be In Production: First Group Must Be In Production: 4-1-20074-1-2007

The second group is to begin The second group is to begin testing no later than 12 months testing no later than 12 months

after the effective date of the rule, after the effective date of the rule, and must be in production no later and must be in production no later than one quarter after the testing than one quarter after the testing

period begins.period begins.

Proposed Claims EDI Implementation Proposed Claims EDI Implementation ScheduleSchedule

The third group is to begin The third group is to begin testing no later than 15 months testing no later than 15 months after the effective date of the after the effective date of the

rule, and must be in production rule, and must be in production no later than one quarter after no later than one quarter after

the testing period begins.the testing period begins.

Proposed Claims EDI Implementation ScheduleProposed Claims EDI Implementation Schedule

When the R3 rules become When the R3 rules become effective and it is the effective and it is the Insurer’s scheduled time to Insurer’s scheduled time to begin submitting DWC-1’s begin submitting DWC-1’s and 13’s via EDI: and 13’s via EDI: An Insurer An Insurer must must submit EDI submit EDI

transactions to the transactions to the Division using the Division using the

national IAIABC national IAIABC Claims EDI Claims EDI

Release 3 Release 3 format. format.

The The Release 3Release 3 Claims Claims Implementation Guide can be Implementation Guide can be downloaded from the IAIABC’s downloaded from the IAIABC’s

website. website.

This guide contains the This guide contains the transaction record layouts, transaction record layouts, data dictionary, scenarios, data dictionary, scenarios,

trading partner trading partner requirements, etc.requirements, etc.

www.iaiabc.org

Then click Then click on on “implement“implementation ation guides”guides”

Florida’s POC EDI Florida’s POC EDI Implementation Manual Implementation Manual is is

available under the EDI link on available under the EDI link on the Division’s website.the Division’s website.

It provides all the FL specific It provides all the FL specific requirements, including requirements, including

required fields, edits and error required fields, edits and error messages.messages.

EDIEDI

www.fldfs.com/WC/www.fldfs.com/WC/

The FL The FL ClaimsClaims EDI EDI Implementation Manual will Implementation Manual will

be revised to match the be revised to match the requirements of requirements of Release 3 Release 3

prior to the filing of the Rule prior to the filing of the Rule 69L-56 amendments 69L-56 amendments

requiring the electronic requiring the electronic reporting of EDI First/Sub reporting of EDI First/Sub

Reports.Reports.

http://www.fldfs.com/wc/http://www.fldfs.com/wc/edi_clms.htmledi_clms.html

Download (at no charge) the Download (at no charge) the EDI Claims R3 EDI Claims R3 Implementation Guide from Implementation Guide from www.iaiabc.org

Become familiar with the Become familiar with the flat file formats, data flat file formats, data elements, etc. elements, etc.

How To Prepare For EDI Claims How To Prepare For EDI Claims Release 3Release 3


Determine what fields you Determine what fields you may have to change or add in may have to change or add in your system to meet the EDI your system to meet the EDI R3 requirements. R3 requirements.

(Ex: EE name must be sent as (Ex: EE name must be sent as separate fields-First, Middle, Last, separate fields-First, Middle, Last, Suffix)Suffix)

Determine if you will do the Determine if you will do the programming “in house” or programming “in house” or use a claims system or use a claims system or vendor that is prepared to vendor that is prepared to handle the R3 format and handle the R3 format and specifications. specifications.

Consider attending Release 3 Consider attending Release 3 training provided by the training provided by the IAIABC EDI Leadership Team. IAIABC EDI Leadership Team. Linda Yon will be one of the Linda Yon will be one of the instructors.instructors.


Analyze the quality of Analyze the quality of your data. If you receive a your data. If you receive a large volume of phone large volume of phone calls/letters from the calls/letters from the Division regarding Division regarding deficiencies of the data deficiencies of the data on your paper forms (ex: on your paper forms (ex: DWC-13), carefully DWC-13), carefully analyze any trends in the analyze any trends in the deficiencies and correct deficiencies and correct them prior to EDI. them prior to EDI.


Examples of Data Deficiencies on Examples of Data Deficiencies on DWC-13’s:DWC-13’s:

DWC-13 filed, but no DWC-1 DWC-13 filed, but no DWC-1 previously filed.previously filed.

IB Benefits paid, but no prior IB Benefits paid, but no prior DWC-4 filed reporting MMI Date DWC-4 filed reporting MMI Date or PI rating.or PI rating.

Examples of Data Deficiencies on Examples of Data Deficiencies on DWC-13’s:DWC-13’s:

Indemnity or Medical benefits Indemnity or Medical benefits previously reported on DWC-13 are previously reported on DWC-13 are not reported on current DWC-13.not reported on current DWC-13.

Indemnity or Medical benefits Indemnity or Medical benefits reported on current DWC-13 are reported on current DWC-13 are less than previously reported on less than previously reported on prior DWC-13.prior DWC-13.

EDI is intended to be a EDI is intended to be a computer-to-computer computer-to-computer exchange of information and exchange of information and less likely to have errors; less likely to have errors; HOWEVERHOWEVER, it is essential , it is essential that claim administrators that claim administrators edit the data as it is input in edit the data as it is input in to their database, and to their database, and before it is sent to the before it is sent to the Division.Division.

All EDI programs at the All EDI programs at the Division have standard Division have standard edits that are applied to edits that are applied to ensure data quality, and ensure data quality, and those edits are provided to those edits are provided to all claim administrators in all claim administrators in the Florida EDI the Florida EDI Implementation Manuals. Implementation Manuals.

The Division will acknowledge The Division will acknowledge every EDI transaction, on the every EDI transaction, on the

standard EDI standard EDI Acknowledgement (AKC) Acknowledgement (AKC)

format.format.This report tells the Claim This report tells the Claim Administrator how many Administrator how many

records passed edits (TA), records passed edits (TA), how many failed how many failed

edits (TR), and the errors that edits (TR), and the errors that caused the record to caused the record to

reject.reject.

ACK ACK

ReporRepor

tt

The EDI Team is proud to The EDI Team is proud to announce its new online announce its new online

web based web based Claims Claims EDI Data EDI Data

WarehouseWarehouse(for existing EDI Trading Partners)(for existing EDI Trading Partners)

This web database will This web database will allow claim allow claim

administrators in any administrators in any field office to have field office to have

access to review the access to review the Claims EDI Claims EDI

transactions they have transactions they have submitted, and any submitted, and any fields that were in fields that were in

error. error.

EDI

Claim Administrators will Claim Administrators will be able to view the actual be able to view the actual data submitted on any EDI data submitted on any EDI transaction, which may transaction, which may appear different than what appear different than what is seen on the claim is seen on the claim administrator’s internal administrator’s internal system. system.

This database will assist This database will assist the claim administrators the claim administrators in resolving EDI errors in resolving EDI errors faster, and may also faster, and may also assist in resolving assist in resolving CPS data issues. CPS data issues.

Claims Claims EDI EDI

WarehouWarehousese

www.fldfs.com/WC/www.fldfs.com/WC/

You can search for an individual claim or query You can search for an individual claim or query by date rangesby date ranges

Claims EDI Data WarehouseClaims EDI Data Warehouse

BESTTPBESTTPAA

SMITH, JOHNSMITH, JOHN 123456712345678989

123451234566

Claim Administrators will also have Claim Administrators will also have instant access to Florida specific instant access to Florida specific (proprietary) performance reports (proprietary) performance reports produced by the EDI Team, and must produced by the EDI Team, and must access this database to receive those access this database to receive those reports. reports. Proprietary Acknowledgement ReportsProprietary Acknowledgement Reports

Monthly Rejected/Not Resubmitted ReportMonthly Rejected/Not Resubmitted Report

Monthly Report CardMonthly Report Card

Note: These Florida Performance Note: These Florida Performance Reports will no longer be sent via Reports will no longer be sent via FTP. Claim Administrators must now FTP. Claim Administrators must now access them via this database. access them via this database.

BESTTPABESTTPA

IAIABC Claims EDI Comprehensive Release 3

Training In Florida


Training In Florida

This 3 day training will be This 3 day training will be given by the national Co-given by the national Co-Chairs of the IAIABC EDI Chairs of the IAIABC EDI Committees and will provide Committees and will provide a detailed overview of the a detailed overview of the Claims EDI R3 Claims EDI R3 Implementation Guide Implementation Guide


Training In Florida

November 29November 29th - th - December December 11stst

Sarasota – Hyatt Sarasota – Hyatt

Space limited to first 150 Space limited to first 150 to submit registration to submit registration with paymentwith payment


Training In Florida

This training will provide critical This training will provide critical instruction for both a “business” instruction for both a “business” person and a person and a “technical/systems” person from “technical/systems” person from within a company.within a company.

To register see the information To register see the information on the IAIABC website under the on the IAIABC website under the “EDI” link.“EDI” link.

EDI Contacts at EDI Contacts at DWCDWCLinda YonLinda Yon

EDI Coordinator 850-413-1702EDI Coordinator 850-413-1702 [email protected]@fldfs.com

Karen KubieKaren KubieClaims EDIClaims EDI 850-413-1703 850-413-1703 [email protected]@fldfs.com

Tonya GrangerTonya GrangerPOC EDIPOC EDI 850-413-1709 850-413-1709 [email protected]@fldfs.com

What is theWhat is the Centralized Performance Centralized Performance

System? System?

A web based, real time interface between A web based, real time interface between insurers/self insurers and the Division of insurers/self insurers and the Division of Workers’ CompensationWorkers’ Compensation

Allows the Division and insurers/self insurers to Allows the Division and insurers/self insurers to monitor payment and filing performancemonitor payment and filing performance

Two modules – Medical and IndemnityTwo modules – Medical and Indemnity

CPS Medical ModuleCPS Medical Module

Review of medical billing payment Review of medical billing payment and and

filing performance by insurer in filing performance by insurer in accordance accordance

with standards set forth in Florida with standards set forth in Florida Statutes, Statutes,

Chapter 440.Chapter 440.


Activated in November 2004Activated in November 2004

Insurers were integrated into CPS as all Insurers were integrated into CPS as all medical data was reported medical data was reported electronically.electronically.

Two key components are:Two key components are:

-- Payment performance evaluationPayment performance evaluation-- Filing performance evaluationFiling performance evaluation

Payment performance componentPayment performance component

Medical bills must be paid, disallowed, Medical bills must be paid, disallowed, or denied within 45 days of the or denied within 45 days of the insurer’s receipt of the bill.insurer’s receipt of the bill.

Performance is measured by a Performance is measured by a statutory performance standard of 95% statutory performance standard of 95% timely payment of bills.timely payment of bills.


Failure to maintain a performance Failure to maintain a performance standard of 95% timely payment standard of 95% timely payment results in the following:results in the following:

$25.00$25.00 per bill for each bill below the per bill for each bill below the 95% timely performance standard, but 95% timely performance standard, but meeting a 90% timely performance meeting a 90% timely performance standard.standard.

$50.00$50.00 per bill for each bill below the per bill for each bill below the 90% timely performance standard.90% timely performance standard.


Violations are calculated Violations are calculated monthly monthly

Performance standard is applied Performance standard is applied to all bills of each individual to all bills of each individual form type DWC9, DWC10, form type DWC9, DWC10, DWC11, and DWC90DWC11, and DWC90


Filing performance Filing performance componentcomponent

Medical bills must be filed with the Medical bills must be filed with the Division within 45 days of the final Division within 45 days of the final disposition of the bill.disposition of the bill.

Failure to meet the 45 days filing Failure to meet the 45 days filing performance results in violations.performance results in violations.


Rejected not Resubmitted Medical BillsRejected not Resubmitted Medical Bills

Bills that have been submitted to the Division butBills that have been submitted to the Division butwere rejected for failure to pass system edits.were rejected for failure to pass system edits.

When the bill is resubmitted properly, it is When the bill is resubmitted properly, it is processed through CPS.processed through CPS.

Failure to resubmit the bill within 90 days of theFailure to resubmit the bill within 90 days of therejection date results in a filing violation.rejection date results in a filing violation.

CPS Indemnity CPS Indemnity ModuleModule

Review of the DWC-1 (Notice of Review of the DWC-1 (Notice of Injury)Injury)

initial payment of compensation initial payment of compensation and and

filing performance as set forth in filing performance as set forth in

Chapter 440, Florida Statutes.Chapter 440, Florida Statutes.

CPS Indemnity ModuleCPS Indemnity Module

Activated in June 2005Activated in June 2005

Analyzes all DWC-1 forms submitted to the Analyzes all DWC-1 forms submitted to the Division in a calendar monthDivision in a calendar month

Evaluates information for two components:Evaluates information for two components:

- Timely payment of initial compensation- Timely payment of initial compensation - Timely filing of the DWC-1 with the Division- Timely filing of the DWC-1 with the Division


The Division monitors the timelinessThe Division monitors the timelinessof the initial compensation payment to of the initial compensation payment to insure injured workers are promptly insure injured workers are promptly compensated as required by law.compensated as required by law.

Failure to provide benefits timely resultsFailure to provide benefits timely resultsin the following…in the following…

Violations for the Late Payment of Violations for the Late Payment of Compensation in accordance with Section Compensation in accordance with Section 440.20, Florida Statutes:440.20, Florida Statutes:

• 20% Penalty on the Unpaid 20% Penalty on the Unpaid InstallmentInstallment

• 12% Interest on the Unpaid 12% Interest on the Unpaid InstallmentInstallment


The DWC-1 must be filed within the time frames The DWC-1 must be filed within the time frames prescribed in Rule 69L-3, F.A.C. in order for the prescribed in Rule 69L-3, F.A.C. in order for the Division to monitor timely payment. FDivision to monitor timely payment. Failure to ailure to timely submit forms will result in a violation as timely submit forms will result in a violation as follows:follows: • $100 1-7 days late

• $200 8-14 days late• $300 15-21days late• $400 22-28 day late• $500 for over 28 days late


CPS BasicsCPS Basics

CPS SystemCPS System

The Medical and Indemnity modules The Medical and Indemnity modules have the following common have the following common characteristics: characteristics:

System setup and site navigation.System setup and site navigation.

Method to review information and Method to review information and process data.process data.

Account administration functions.Account administration functions.

A few common definitions:A few common definitions:

BatchBatch:: A monthly assessment of all information A monthly assessment of all information submitted in one calendar month.submitted in one calendar month.

Summary pageSummary page:: CPS overview of all information on an CPS overview of all information on an insurer’s batches.insurer’s batches.

WorkbenchWorkbench:: The page where batches are processed by The page where batches are processed by insurers/self insurers. This is where all “work” is done.insurers/self insurers. This is where all “work” is done.

StageStage:: The timeframe for the insurer/self insurer to work The timeframe for the insurer/self insurer to work on the batch and respond to the Division.on the batch and respond to the Division.

CPS StagesCPS Stages

Preliminary Notice of ViolationPreliminary Notice of Violation - The initial - The initial 30 day period for the insurer to review the 30 day period for the insurer to review the Division’s identification of untimely payments and Division’s identification of untimely payments and filings, to dispute/concur with the information, filings, to dispute/concur with the information, provide additional information or correct data, pay provide additional information or correct data, pay and resolve the batch. and resolve the batch.

Notice of ViolationNotice of Violation – Administrative order by the – Administrative order by the Division to the insurer of the outstanding Division to the insurer of the outstanding unresolved violations.unresolved violations.

Formal HearingFormal Hearing – Should the insurer dispute the – Should the insurer dispute the violations, they can preserve their rights and violations, they can preserve their rights and request an administrative hearing.request an administrative hearing.

A few more definitions:A few more definitions:

Insurer Statuses:Insurer Statuses:DisputeDispute: The Insurer has reviewed the CPS : The Insurer has reviewed the CPS information upon which a violation is asserted information upon which a violation is asserted and does not agree that a violation has occurred.and does not agree that a violation has occurred.

ConcurConcur: The Insurer has reviewed the CPS : The Insurer has reviewed the CPS information and agrees that the violation is valid.information and agrees that the violation is valid.

Data Correction SentData Correction Sent – The insurer has sent – The insurer has sent corrected information for the CPS to review.corrected information for the CPS to review.

CPS TutorialCPS Tutorial

Power point presentationPower point presentation

Can be downloaded and utilized for Can be downloaded and utilized for training purposestraining purposes

It is It is onlyonly the Indemnity Module. the Indemnity Module. However, it is useful in learning However, it is useful in learning either systemeither system

CPS Logon PageCPS Logon Page

The CPS Home Page… The CPS Home Page… status barstatus bar

Online Help FilesOnline Help Files

Can be accessed from any screen in CPSCan be accessed from any screen in CPS

Separate help files for each moduleSeparate help files for each module

Menu bar…Menu bar…

Feedback….Feedback….

The Centralized The Centralized Performance Performance System System Administrative Administrative FunctionsFunctions

The Insurer Administrator:The Insurer Administrator:

Is the primary contact for the insurer Is the primary contact for the insurer in CPSin CPS

Creates new sub-accounts (users)Creates new sub-accounts (users)

Edits the permissions of sub-accountsEdits the permissions of sub-accounts

CPS Insurer CPS Insurer AdministratorAdministrator

To create a sub-account…To create a sub-account…

Account Creation…Account Creation…

Account Access RightsAccount Access Rights

View Items and Add Notes:View Items and Add Notes: This is the basic level of This is the basic level of permission to allow the viewing of CPS data and to add notes to permission to allow the viewing of CPS data and to add notes to CPS batches.CPS batches.

View Items and Update Status:View Items and Update Status: This secondary level of This secondary level of permission may view items, add notes, assign statuses of permission may view items, add notes, assign statuses of concur/dispute to preliminary violations.concur/dispute to preliminary violations.

Submit Batches:Submit Batches: This is the broadest permission level. Users This is the broadest permission level. Users can view items, add notes, assign statuses, and submit batches can view items, add notes, assign statuses, and submit batches to the Division. By default this permission is given to each to the Division. By default this permission is given to each company’s Insurer Administrator. company’s Insurer Administrator.

Claims Handling Entity Claims Handling Entity assignment…assignment…

Claims Handling Entity Claims Handling Entity Access RightsAccess Rights

Claims Handling Entities (CHE) have a Claims Handling Entities (CHE) have a separate login in the Indemnity module.separate login in the Indemnity module.

CHEs can view all DWC-1s submitted to CHEs can view all DWC-1s submitted to the Division with their CHE code.the Division with their CHE code.

The insurer administrator can grant higher The insurer administrator can grant higher level access to allow the CHE to respond level access to allow the CHE to respond to the violations.to the violations.

The CHE can do all necessary work The CHE can do all necessary work exceptexcept submit batches on the insurer’s submit batches on the insurer’s behalf. behalf.

OvervieOvervieww

Welcome screen…Welcome screen…

Summary …Summary …

Workbench…Workbench…

Detail page options…Detail page options…

Summary information from the DWC-1Summary information from the DWC-1

Key Dates

Penalties assessed

Contacts

Responding to a Responding to a violation…violation…

Wor

Work Area to concur/dispute penalties andAdd notes/upload documents

The View All Screen … from the The View All Screen … from the top headertop header

View All screen… bottom of the pageView All screen… bottom of the page

MS Excel Output…MS Excel Output…

CSV Output…CSV Output…

Batch SubmissionBatch SubmissionWhen an insurer has responded to all violations When an insurer has responded to all violations assessed in the batch they may submit it to the Division.assessed in the batch they may submit it to the Division.

The Division will review the response, make any The Division will review the response, make any necessary data revisions/corrections, and accept or necessary data revisions/corrections, and accept or deny the insurer’s disputes. deny the insurer’s disputes.

The Division will return the batch to the insurer for The Division will return the batch to the insurer for review.review.

This process continues until the insurer/Division agree This process continues until the insurer/Division agree on the violations and payment is made or the insurer on the violations and payment is made or the insurer proceeds to the Notice of Violation stage.proceeds to the Notice of Violation stage.

A close up of the buttons…A close up of the buttons…

The Confirmation page…The Confirmation page…

Batch Payment Options:Batch Payment Options:There are two payment options There are two payment options available at any time.available at any time.

A A Full Payment Full Payment is simply the total is simply the total batch payment amount.batch payment amount.

A A Partial Payment Partial Payment is the sum of all is the sum of all concurred filing penalties in a batch.concurred filing penalties in a batch.

Making Payment to the DivisionMaking Payment to the Division

Payment Entered for full or partial Payment Entered for full or partial paymentpayment

The Reports Tab…The Reports Tab…

Select a date range…Select a date range…

How is your company performing vs. How is your company performing vs. industry?industry?

Medical Module – Additional Functions

Rejected but not resubmitted medical billsRejected but not resubmitted medical bills

Medical ReportsMedical Reports

Common Errors - Common Errors - IndemnityIndemnity Incorrect coding of case Incorrect coding of case

type: type: ML or LTML or LT

Failure to input all key datesFailure to input all key dates

Failure to input penalties & Failure to input penalties & interest already paid in first interest already paid in first installmentinstallment

Common Errors - Common Errors - MedicalMedical

Incorrect insurer/claims handling Incorrect insurer/claims handling entity codingentity coding

Incorrect payment datesIncorrect payment dates

Rejected bills are not promptly Rejected bills are not promptly corrected and resubmittedcorrected and resubmitted

The Key to success is The Key to success is

Data Quality!Data Quality!

Questions?Questions?

Should you have further questions contact Should you have further questions contact Robin Ippolito or your assigned specialist Robin Ippolito or your assigned specialist at 1-850-413-1608.at 1-850-413-1608.

Florida Division of Florida Division of Workers’ CompensationWorkers’ Compensation

Centralized Centralized Performance SystemPerformance System

Robin IppolitoRobin Ippolito

Bureau of Monitoring & AuditBureau of Monitoring & Audit

[email protected]@fldfs.com

Division of Workers’ Division of Workers’ Compensation 2005Compensation 2005

Bureau of Monitoring and Bureau of Monitoring and AuditAudit

Today’s Discussion:Today’s Discussion:

Practices that Drive Audit Practices that Drive Audit CostsCosts

Looking Back Over The Past Looking Back Over The Past Year’s Audit PerformanceYear’s Audit Performance

Evolution of the Audit ProcessEvolution of the Audit Process


Poor Practices that Drive Audit Poor Practices that Drive Audit Costs:Costs:

1. DWC-1 Untimely Filings1. DWC-1 Untimely Filings

2.2. Untimely Payment of Medical Bill Untimely Payment of Medical Bill

3.3. Permanent Total Benefit Permanent Total Benefit CalculationsCalculations

Poor Practices Poor Practices Driving Audit CostsDriving Audit Costs

Timely Filing of DWC-1s:Timely Filing of DWC-1s:

File on indemnity settlements File on indemnity settlements of any typeof any type

If Impairment Income Benefits If Impairment Income Benefits is the first indemnity benefit is the first indemnity benefit paid, you must file the DWC-1 paid, you must file the DWC-1 upon payment of these benefitsupon payment of these benefits


Timely Payment of Indemnity & Timely Payment of Indemnity & Medical Benefits:Medical Benefits:

Prior to January 1, 2004 Prior to January 1, 2004 90% Performance Standard 90% Performance Standard

Post January 1, 2004 Post January 1, 2004 95% Performance Standard 95% Performance Standard


Permanent & Total Benefit Permanent & Total Benefit Calculations:Calculations:

Inaccurate calculation of PT benefits & Inaccurate calculation of PT benefits & PT Supplemental benefitsPT Supplemental benefits

Timely payment of PT benefits and PT Timely payment of PT benefits and PT Supplemental benefitsSupplemental benefits

Social Security Disability offset Social Security Disability offset calculationscalculations

Grice limitationsGrice limitations

FY 2004-05 Audit FY 2004-05 Audit ResultsResults

A Summary of Audit Performances A Summary of Audit Performances in the Following Areas:in the Following Areas:

Timely Payment of IndemnityTimely Payment of Indemnity

Timely Payment of Medical Timely Payment of Medical

Timely Reporting of the DWC-1Timely Reporting of the DWC-1

Timely Reporting of the DWC-13Timely Reporting of the DWC-13

Timely Sending of Employee BrochuresTimely Sending of Employee Brochures

Timely Payment of Timely Payment of CompensationCompensation

Timely Payment of MedicalTimely Payment of Medical

Timely Reporting of DWC-1Timely Reporting of DWC-1

Timely Reporting of DWC-13Timely Reporting of DWC-13

Timely Mailing of Employee Timely Mailing of Employee BrochuresBrochures

Medical Bills Evaluated by CPS Medical Bills Evaluated by CPS Since November 2004 Since November 2004

November-04

December-04

January-05 February-05

March-05 April-05 May-05 June-05 July-05

27,39081,097

172,278159,013

228,482

423,950

484,581

393,457 393,457

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

Latest CPS Performance Latest CPS Performance Medical Data for July 2005Medical Data for July 2005

DWC-09

DWC-10

DWC-11

DWC-90

96%

93%98%98%

90%

91%

92%

93%

94%

95%

96%

97%

98%

DWC-09

DWC-10

DWC-11

DWC-90


Our Audit Process has been Impacted by:Our Audit Process has been Impacted by:– Claims Rule (69L-3) Claims Rule (69L-3) – Medical Billing Rule (69L-7.602)Medical Billing Rule (69L-7.602)– Upcoming EDI – Indemnity Mandate (69L-56)Upcoming EDI – Indemnity Mandate (69L-56)– The Centralized Performance SystemThe Centralized Performance System


Changing How We Review the First Changing How We Review the First Report of Injury (DWC-1)Report of Injury (DWC-1)– Timely Reporting of the DWC-1 and Initial Timely Reporting of the DWC-1 and Initial

Indemnity Payment Assessed by CPSIndemnity Payment Assessed by CPS– Audit Will Focus on Data Quality Reported to Audit Will Focus on Data Quality Reported to

DWC (Claim File is the Source Document)DWC (Claim File is the Source Document)


Changing How We Review Medical BillsChanging How We Review Medical Bills– Timely Payment and Timely Reporting of Timely Payment and Timely Reporting of

DWC-9, DWC-10, DWC-11 and DWC-90 is DWC-9, DWC-10, DWC-11 and DWC-90 is Now Assessed by CPSNow Assessed by CPS

– Audit Will Focus on Data Quality Reported Audit Will Focus on Data Quality Reported to DWC (Claim File is the Source to DWC (Claim File is the Source Document)Document)

New & Essential Audit New & Essential Audit ComponentsComponents

Insurers / Claims-handling Entities Insurers / Claims-handling Entities Must Have Documented Processes and Must Have Documented Processes and Procedures (in writing).Procedures (in writing).

Expect a Complete Review of :Expect a Complete Review of :

1.1. Step-by-Step Check IssuanceStep-by-Step Check Issuance

2. Step-by-Step Date Stamping 2. Step-by-Step Date Stamping

3. Step-by-Step Mailroom 3. Step-by-Step Mailroom OperationsOperations


IMPORTANT NOTE:IMPORTANT NOTE:

Electronic Systems Must be Electronic Systems Must be Transparent For Audit PurposesTransparent For Audit Purposes

1.1. Medical DataMedical Data2.2. EDI DataEDI Data3.3. Payment InformationPayment Information4.4. All Adjuster Notes / CommentsAll Adjuster Notes / Comments


Implementation of CPS Provides More Implementation of CPS Provides More Time:Time:– Indemnity CalculationsIndemnity Calculations– Permanent Total CalculationsPermanent Total Calculations– Indemnity TimelinessIndemnity Timeliness– Forensic Review of Claim FileForensic Review of Claim File

Bureau of Monitoring and AuditBureau of Monitoring and Audit

IMPORTANT NOTE:IMPORTANT NOTE:

Insurers / Claims-handling Entities Insurers / Claims-handling Entities Must Improve the Documentation in Must Improve the Documentation in a Claim File (If it isn’t in the claim a Claim File (If it isn’t in the claim file, you didn’t do it)file, you didn’t do it)

Bureau of Monitoring & Bureau of Monitoring & AuditAudit

Thank You!Thank You!

Greg Jenkins, ChiefGreg Jenkins, Chief


Phone: 850-413-1775Phone: 850-413-1775

Email: Email: [email protected]@fldfs.com

Florida Division Of Workers Compensation Employee Assistance and Ombudsman Office FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief.

Documents

injured workers

adjuster slide

work slide

involvement slide

workers compensation

injured worker eao

workers compensation

eao eao vision