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Claims manager audit reveals medical review, benefits deficiencies

Posted On: Oct. 16, 2018 12:59 PM CST

Claims manager audit reveals medical review, benefits deficiencies

The California Division of Workers’ Compensation issued 1,569 citations to workers comp claims handlers in 2016 who had failed to comply with requirements stemming from the process for using qualified medical examiners in claims management, according to an audit report released Monday.

The annual report provides information on how claims administrators performed and the types of violations cited. While the division issued the most citations for failing to comply with the qualified medical examiner process, totaling $207,164 in fines, the most costly in terms of fines were the 525 citations issued for late first payment of temporary indemnity benefits — totaling $208,300 in fines, according to the report.

Failing to pay any temporary disability also proved costly in fines, with 240 citations totaling $185,000, according to the report. Failure to pay or object to medical treatment expenses was another major violation, with 273 citation issued totaling $111,555.

In all, the division issued 3,736 citations to claims managers, totaling $986,515 in fines. The division eventually collected $442,547, with just over half not subject to assessment, according to the report. The new figures are a significant drop from what was collected the previous year in fines: $1 million.   

This report to the Legislature summarizes audits conducted in accordance with law passed in 2009 to ensure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner, according to the statement.