Division of Workers Compensation 2004

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Division of Workers Compensation 2004
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Todays Presenters / Issues

• Greg Jenkins - Global Overview, Data and
  Statistics, Monitoring Process, What to Expect in
  an Audit
• Fred Becknell Linda Yon Rule 69L-3 Form
  Changes, Rule 69L-56, New Data Requirements
• Don Davis - Data Quality Control, Medical
  Reimbursement Rule.
• Robin Ippolito - The Centralized Performance
  System (CPS)

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Division of Workers Compensation

• How a comprehensive and cohesive approach to
  enforcing the workers compensation law impacts
  you!

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The Importance ofQuality Timely Data

• Data is essential to assuring the health of the
  workers compensation system
• All system participants are dependent on quality
  data
• Sophistication of data needed is increasing as
  the demand for data increases.

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Divisions Role Quality and Timely Data

• The Division is committed to
• Providing the industry with clear and articulate
  rules on the submission of required data
• Auditing to assure the quality timeliness of
  data
• Assessing data in a real time environment
• Providing stakeholders with essential information
  based on data

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Claims-Handling Practices

• Implementing Sections 440.525 440.20
• Availability of more sophisticated data allows
  focused analysis
• Statutory authority for examination
  investigation is strong
• Performance standards have increased

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Claims-Handling Practices

• A more forensic review of claim files
• Patterns Practices, Section 440.525 (2) (3)
• harassment, coercion or intimidation of claimants
• unreasonable delays in claim handling
• timeliness and accuracy of payments and reports
• An established pattern or practice shall result
  in a violation (willful or nonwillful)

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Claims-Handling Practices

• Mandatory electronic reporting of claims
  medical data through EDI
• and MDS will impact how we audit!
• Comparing electronic data to source information
• More time for forensic review of claim file

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Bureau of Monitoring and Audit

• Our Audit Process - How does it work?
• We determine the audit schedule using monitoring
  information and rotational schedule
• Audit duration Generally 1 or 2 weeks
• Currently there are 3 audit teams .. we may
  allocate one or more teams to any given audit

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Bureau of Monitoring and Audit

• (Continued)
• Our Audit Process - How does it work?
• Size of audit
• Higher levels of non-compliance will increase the
  size of the sample
• The larger the claims volume, the larger our
  sampling

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FOCUSBureau of Monitoring and Audit

• Basic Elements of an Audit -
• Timely Medical Payments
• Note Old / New Standards
• Timely Accurate Indemnity Payments
• Note Old / New Standards
• Accurate Timely Filing of Forms
• Patterns Practice

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Bureau of Monitoringand Audit

• How an audit runs more smoothly.
• Pre-Audit Process
• Respond timely to initial and subsequent
  information requests
• Know your data! Make certain you have thoroughly
  reviewed and confirmed the accuracy of the claims
  data you provide us for audit.

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Bureau of Monitoring and Audit

• Plan ahead be prepared for our visit
• Facility / Space Issues
• Administrative Issues (Parking, identification
  badges)
• Information System Issues
• Read-only access
• Computer availability

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Bureau of Monitoring and Audit

• How an audit runs more smoothly.
• Audit and Post-Audit Process
• Promptly provide claim files and other
  information requested
• Manage the timely review and return of
  clarification sheets
• Respond to audit reports within allotted time
  frame

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Bureau of Monitoring and Audit

• Thank You!
• Greg Jenkins, Chief
• Bureau of Monitoring and Audit
• Phone [phone]
• Email jenkinsg_at_dfs.state.fl.us