Commonly Seen Errors In Department Audits And How To Fix Them

Commonly Seen Errors In Department Audits

And How To Fix Them.

Rights & Obligations

WAC 296-15-400 Within 30 days of Hire

Substantially Similar/WAC 296-15-001

Problems Found in Audits Not using form Modifying form

Not providing form to all new employees

Recommendations– Form available on L & I website– Add to orientation checklist

When Worker Files A Claim– Provide Department booklet– Names, address, phone number of person or

organization handling claim

Problems Found in Audits– Not providing booklet– Timely providing

Recommendations

– Booklet available on Department website or can be ordered from Department

– Provide with SIF-2

Claim Filing Procedure Errors

WAC 296-15-320

Problems Found in Audits– Providing Self-Insurer Accident Report (SIF-2)

when notified of injury or illness– Timely delivery of completed (SIF-2s) to claim

management entity – Only Department provided SIF-2s may be used

Notice of self-insurance

RCW 51.14.100(1)

Problems Found in Audits Substantially identical form

Listing person or position on site State Fund Notices

Reasonable number of notices

Recommendations

– Form available on Department website

Claims Log

WAC 296-15-200 Designate location of official log in writing

Problems Found in Audits

Date claim closed by Order and Notice

Whether claim is time loss or medical only

Unreported claims

Onsite Medical Treatment

Medical facilities and employers who treat their workers at their onsite medical facility

Treatment by physician, nurse practitioner, physician assistant, or registered nurse under doctors standing orders

Provide injured worker with opportunity to file claim form (SIF-2)

Documentation of refusal and notification of one-year filing statute.

Treatment log for medical only claims with treatment exclusively at employer’s medical facility.

Date stamping incoming correspondence

WAC 296-15-350(8) Legibly date stamp with date received and

where received Includes doctor notes, activity prescription

forms, state fund accident reports, physicians initial reports, and other reports received by employer or claims management entity

Punch dates are not legible

Failure to request allowance or denial within 60 days from date claim filed

RCW 51.14.130 and WAC 296-15-420 Check for allowance orders Does not apply to medical only claims unless

requesting denial or interlocutory order Penalty per RCW 51.14.140 and RCW

51.48.080

Payment of first time loss within 14 days

RCW 51.32.190(3) Payment within 14 days after notice of a claim Notice of claim or claim arrival date

– Injured worker makes application for benefits – Claim elements-description of injury, diagnosis of

medical condition, treatment or treatment recommendation

– Hospitals and employers with onsite medical facility

Recommendations– Review process of filing claims– Communication, communication, communication– Training employees

Benefits Not Paid as Entitled

RCW 51.32.010 Communication, communication,

communication Learn the employer’s payroll system WAGES/ RCW 51.08.178

– Obtain & review daily payroll records to determine employment pattern

– Averaging hours• Use full weeks and full months

Multiple rates of pay– Substantial number of hours at different rates of

pay, treat each as separate rate of pay– Rates of pay at time of injury– Change of circumstances

• Raises• Change of jobs• Change of shifts

Health Care Benefits (medical, dental, vision) Bonuses Loss of Earning Power Benefits

– Communication, communication, communication– Determine if eligible any time return to work light or

modified duty– Eight hours versus average daily hours– Updated date of injury wages– Bonuses

C.O.L.A. – July 1

Return to Modified or Light Duty Work

RCW 51.32.090(4) Communication, communication,

communication Provide worker with copy of light duty job

description when contacting physician for release to light duty

Document light duty offer and injured worker’s decision

Determine if LEP due

SIF-5 Information

WAC 296-15-420 and WAC 296-15-450 Required for Department to monitor claim and

make determinations Should report what has taken place at time of

completion

Most common SIF-5 errors– Date of first payment– Release for work date– Return to work date

Final report includes all dates- light duty, full duty

Employer Closures

RCW 51.32.055 (9) (a) Jurisdictional errors

– Did not return to work with employer of record– Null and Void Orders

WAC 296-15-450(6)– Untimely filing of EC Order and Final SIF-5

Medical Only Claims

Communication, communication, communication

May become compensable claim Determine if LEP due for return to work light

duty Verify return to work full duty

Worker Hours

Salaried Employees WAC 296-17-31021(2)

– Report all salaried employees by same method– Actual hours worked or assumed 160 hours per

month– Complete and accurate time records of all hours

worked, whether paid or not

Personal Services Labor Contracts

RCW 51.08.180 and RCW 51.08.195 Independent contractor providing essentially

personal labor for employer is a worker Must meet ALL six parts of test described in

RCW 51.08.195 to be exempt

Department Web Site

RCWs, WACs, Forms, Publications, Self-Insurance information

lni.wa.gov/ClaimsIns/Insurance/SelfInsure/ At lni.wa.gov web site, click on Business

Links, then Self-Insurance