WORKERS’ WORKERS’ COMPENSATION COMPENSATION

MONITORING MONITORING PROGRAMPROGRAM

THIRD PARTY THIRD PARTY ADMININSTATORS ADMININSTATORS

(TPA)(TPA) TRISTAR - RANCHO (UNIT 1)TRISTAR - RANCHO (UNIT 1)

TRISTAR - SANTA ANA (UNIT 2)TRISTAR - SANTA ANA (UNIT 2)

INTERCARE (UNIT 3)INTERCARE (UNIT 3)

AIMS (UNIT 4)AIMS (UNIT 4)

WORKERS’ WORKERS’ COMPENSATIONCOMPENSATION

MONITORSMONITORS

ALEX ROSSICounty Contract Administrator

TONY TARASCPS – Workers’ Compensation

ROSE BLOOMSupervising QAE – Units 1 and 2

JOE CARRILLOSupervising QAE – Units 3 and 4

TONI VUQAE – Tristar Unit 1

MARK LEBLANCQAE – Tristar Unit 2

PAM KENNEDYQAE – Intercare Unit 3

ERNIE ROMOQAE – AIMS Unit 4

CHRIS HURREYQAE – AIMS Unit 4

““The Quality Assurance Evaluator is a The Quality Assurance Evaluator is a County employee designated as an County employee designated as an agent for the County responsible for agent for the County responsible for monitoring the Contractor’s monitoring the Contractor’s performance, approving over limit performance, approving over limit payments, advising and training third payments, advising and training third party administrator staff in County party administrator staff in County payroll systems and other County payroll systems and other County procedures. At times this employee procedures. At times this employee may be referred to as ‘County may be referred to as ‘County Monitor’.”Monitor’.”

DUTIES OF THE COUNTY DUTIES OF THE COUNTY MONITORMONITOR

Review all delayed claims at Review all delayed claims at 30/60/90 day intervals30/60/90 day intervals

Approve all litigation referrals to Approve all litigation referrals to County CounselCounty Counsel

Approve all award paymentsApprove all award payments Approve all payments over Approve all payments over

$7,500.00$7,500.00 Provide training to TPA staffProvide training to TPA staff

DUTIES OF THE COUNTY DUTIES OF THE COUNTY MONITORMONITOR

Assist TPA staff on balancing of complex Assist TPA staff on balancing of complex casescases

Analyze claims and provide settlement Analyze claims and provide settlement recommendations and authorityrecommendations and authority

Address questions and concerns of Address questions and concerns of injured workers, County departments, injured workers, County departments, and defense attorneys and defense attorneys

Attend claim reviewsAttend claim reviews Conduct annual audit of the TPA’sConduct annual audit of the TPA’s

LIAISON BETWEEN LIAISON BETWEEN DEPARTMENTS AND THIRD DEPARTMENTS AND THIRD PARTY ADMINISTRATORSPARTY ADMINISTRATORS

CLAIM REVIEWSCLAIM REVIEWS

Reviews should be held at least Reviews should be held at least quarterly with County Monitors, quarterly with County Monitors, CEO RTW personnel, Departmental CEO RTW personnel, Departmental RTW personnel, Loss Control, and RTW personnel, Loss Control, and County Counsel.County Counsel.

Don’t overload! If necessary, Don’t overload! If necessary, schedule more frequent claim schedule more frequent claim reviews.reviews.

CLAIM REVIEWSCLAIM REVIEWS

File Selection:File Selection: Choose files with complex claims or Choose files with complex claims or

RTW issues.RTW issues. Get input from your TPA’s, County Get input from your TPA’s, County

Monitors, and Counsel.Monitors, and Counsel. ““Out of service” does not mean “out Out of service” does not mean “out

of sight, out of mind”!of sight, out of mind”!

CLAIM REVIEWSCLAIM REVIEWS

What we need from you:What we need from you: Information about any RTW efforts that have been Information about any RTW efforts that have been

mademade Information about any disciplinary action being Information about any disciplinary action being

taken against the injured worker (unless taken against the injured worker (unless confidential)confidential)

Information about any other action the injured Information about any other action the injured worker is taking against the County (unless worker is taking against the County (unless confidential)confidential)

Type of retirement planType of retirement plan Out of service date and termination reason, if anyOut of service date and termination reason, if any

ANNUAL TPA AUDITSANNUAL TPA AUDITS We randomly select 80 files to audit We randomly select 80 files to audit

TPA performance during a defined TPA performance during a defined period.period.

TPA’s are scored on 37 questions TPA’s are scored on 37 questions assigned weights based on level of assigned weights based on level of importance.importance.

A total score is calculated based on A total score is calculated based on the weighted scores in each the weighted scores in each category.category.

There are “mutually beneficial There are “mutually beneficial performance and financial performance and financial incentives” applied based on the incentives” applied based on the total score. total score.

ANNUAL TPA AUDITSANNUAL TPA AUDITS

CHANGES IN 2009:CHANGES IN 2009:

Vocational rehabilitation Vocational rehabilitation questions have been eliminatedquestions have been eliminated

New questions on:New questions on: State Panel QME ProcessState Panel QME Process Supplemental Job Supplemental Job

Displacement Displacement Work Restriction LettersWork Restriction Letters

WORK WORK RESTRICTION RESTRICTION

LETTERSLETTERS

QUESTIONS?QUESTIONS?