Kim Tallarida , Sedgwick CMS
Kelly Early, ESD #113

The Liaison Committee met with the representatives from the Department of Labor & Industries on May 12, 2010.  Please contact either Kim Tallarida at 206-262-4404 ktallarida@sedgwickcms.com, or new Employer Liaison Representative Brian Earl at 425-917-7636  bearl@psesd.org with any issues you would like to have discussed at our next meeting scheduled for July 7, 2010.

The meeting opened with some updates provided by the Department of Labor and Industries. 

Annalisa introduced the new Claims Operations Manager, Candice Myrum, to the group.  Candice supervises the two claims unit supervisors, pension staff, and our support staff supervisor (Please refer to the organizational chart for further details)

Annalisa offered to invite people from  other department areas (e.g. OMD, HSA) as resources to address our concerns, depending on the agenda items we bring forward.  She also offered the ability to have additional stand-alone meetings as needed, as well as lengthening the amount of time set aside for our current standing meetings.

Anita Austin gave an update on the IME Improvement project.  The IME worker surveys have been distributed to the IME companies, as well as the physician’s who perform IME’s in their offices.  10,000 copies have been sent out with an additional 20,000 copies currently in process.  There was some discussion about reviewing the results, and that the first round of results will be available in July.  There was agreement that having the results aggregated, and separated out by Self Insured and State Fund, would be helpful. 

The new provider WAC accidentally eliminated all general dentists from performing IME’s.  There is a proposed WAC change required to fix this error. 

An RFP will be out shortly for electronic IME scheduling.  (This is related to the State Fund)

Gary Walker is working on testimony and IME no-show fee enforcement, and will be invited to our July 7, 2010 Liaison Committee meeting.

PROTEST DETERMINATIONS   

As of April 18, 2010 there are a total of 779 pending protests, with 62 over 180 days.  Claim Adjudicators had 195 pending with 9 over 180 days.  As of April 18, 2010 the Claim Consultants had 584 pending with 53 over 180 days.  The oldest claim is 842 days, and involves a claimant who cannot be located, and ahearing loss issue.

VOCATIONAL DETERMINATIONS

The Department is current, and there is no backlog.  For April 2010, there were 97 Self-Insurance Vocational Referral Forms (SIVRF’s took the place of E.A.R.’s) submitted for eligibility, 23 were found eligible, 12 plans were approved and 8 chose option 2. 

The question was asked that the Department see if we can get a report that shows the number of Option 2 recipients who are using their vocational benefits.  There have been no reported repeat customers for vocational services as of April 30, 2010.  We were told about a past protest/appeal regarding an option 2.  In the case, the injured employee selected option 2, received the funds, received PPD at the time of closure, then protested/appealed the closure and requested a pension.   The Department will give us an update on the outcome of this case, and and any other option 2 court cases at the next meeting.

PENSION DETERMINATIONS

There are 73 pending pension requests, of which 38 are waiting on additional information.  The oldest submitted Pension request is from December 2009.  Since our last report, there were 2 requests for post pension treatment orders.

PAY DURING APPEAL STATUS

There have been 178 stay of benefits requested (both State Fund and self-insured, with most being self-insured) and 16 granted (all but 1 of the granted is self-insured).  Some 146 of those were denied, 4 are waiting on decisions, and 12 requests for a stay have been withdrawn.  To date, there has still only been one penalty issued for a delay in benefits.

The Department of Labor and Industries sent out 22 letters to injured employee’s where pay on appeal may apply to their claim.

No requests for reimbursement from the Self-Insurer Overpayment Reimbursement Fund have yet been received.

CLAIM DELAYS

ORCA/ORION are not impacting the delays.  The current issue is staffing.  The two half-time adjudicator positions were cut in the 2009 reductions, and cannot be replaced. In addition, the claims units have two employees out on long term.  The latest numbers are that 65% of closures are processed within 30 days, with 89% of closures approved on the first review.  Annalisa is looking for additional approval for temporary employees that she has had helping to reduce the backlog.  Those temporary employees issued 179 closing orders and 623 wage orders in their 4 weeks of work.

SPECIFIC CLAIM ISSUES

Three claims were brought by the Liaison Committee for delay issues and all three claims closed on 3/18/10.

ISSUANCE OF TEMPORARY AGGRAVATION ORDERS

The underlying issue was an operations issue for the State Fund, not a policy change.  The state fund does not generally issue these types of orders, and so the self insured section stopped in an effort to be consistent internally within self-insurance and with the State Fund (a constant complaint from the self-insured community to the Department).  Based on input from the community, the self insured section will continue to issue temporary aggravation orders, and there will be some focused training with the self insured adjudicators to refresh them on temporary aggravation orders and when to issue them appropriately.

CRITERIA AND PROCESS FOR REOPENINGS

There was lengthy discussion regarding the reopening process – the Department of Labor and Industries sends a letter to the TPA or Self Administered employer when a reopening application is received.  What we found was that some of these applications may be received by the TPA or Self Administered employer, which then should be sent to the Department of Labor and Industries.  It is important to note that the clock for addressing reopening starts the date received by either the DLI or the TPA or Self Administered employer.  Concern had been expressed that delayed notification meant delayed action on the part of the employer in attempting to either support or oppose the reopening.

SIEDRS UPDATE AND ISSUES

There was no new information provided.  Discussions on this important issue will continue at future meetings.

NEW SELF-INSURED EMPLOYERS/ SURRENDERS SINCE 1/1/09

No new approvals since 7/1/2009, 1 default 5/15/10, 1 surrender 3/31/10 and two applications have been filed for 7/1/10.

SPECIFIC PENSION CLAIM ISSUE

A pension order was issued, and the self insured employer protested this pension order to backdate the order.  There was a process flow problem that was identified that the Department is working through.  Once a pension order has been issued, the claim is sent on to headquarters to the pension benefit specialists for further handling.  When the protest or mail is sent in, the pension specialist is not sharing that information with the Self-Insurance Section pension adjudicator.  While this workflow is being addressed internally, it is suggested that the self-insured employer follow up with the Department pension adjudicator to inform them of the protest.  Once they identify the protest, they can take more prompt action.

CHANGES TO SELF INSURER AUDIT PROCESS

Discussions on this important issue will continue at future meetings.

 (Was added to the agenda at the last minute)

CERTIFIED CLAIMS ADMINISTRATOR CONTINUING EDUCATION CREDITS

Discussions on this important issue will continue at future meetings.

 (Was added to the agenda at the last minute)

posted 28 July 2010

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