Monitoring Compliance Timely SROI showing Initial Payment Timely

Monitoring & Compliance Timely SROI showing Initial Payment Timely Installment

October 15, 2021 2 Agenda 1. Introductions/Welcome 6. Ways to Improve 2. How We Are Measuring 7. No Medical • Timeliness of SROI showing Initial Payment 3. Monitoring Compliance 8. Request for Review Process • Timeliness of SROI showing Initial Payment 4. How We Are Measuring • Timeliness of Initial payment of Compensation and Installment Payment 5. Monitoring Compliance • Timeliness of Initial payment of Compensation and Installment Payment 2 9. Invoice 10. Wrap-Up/Questions

October 15, 2021 Payor Compliance The Board will be measuring timeliness of the Subsequent Report of Injury (SROI) showing initial payment, timeliness of initial payment and timeliness of installment payment. The Board will begin to measure SROI transactions received in the first quarter of 2017 on claims with a date of accident of 5/23/14 or after. Penalties will be issued in April of 2017. 3 3

October 15, 2021 4 HOW WE ARE MEASURING Timeliness of SROI showing Initial Payment of Compensation 4

October 15, 2021 5 How We Are Measuring Timeliness of SROI showing Initial Payment of Compensation Enforcement of the 18/10 Day Rule defined in WCL Section 25(1)(c): If the employer or insurance carrier does not controvert the injured worker’s right to compensation such employer or insurance carrier shall, either on or before the 18 th day after disability, OR within 10 days after the employer first has knowledge of the alleged accident, whichever period is the greater, begin paying compensation and shall immediately notify the chair in accordance with a form prescribed by him, that the payment of compensation has begun, accompanied by the further statement that the employer or insurance carrier, as the case may be, will notify the chair when the payment of compensation has been stopped. 5

October 15, 2021 6 How We Are Measuring Determination of Dates Used for Measurements Employer Knowledge Date To Determine Employer Knowledge Date — the Board will use the earliest date of Date Employer Had Knowledge of the Injury (DN 0040), Date Employer Had Knowledge of Disability (DN 0281), Assembly Notice Date, Indexing Notice Date. Initial vs Current Date Disability Began To Determine use of Initial Date Disability Began or Current Date Disability Began — If Initial Date Disability Began (DN 0056) and Current Date Disability Began (DN 0144) are present, and the Initial Return to Work Date (DN 0068) is less than or equal to 7 days then Current Date of Disability (DN 0144) is used. 6

October 15, 2021 Scenario 7 Timeliness of SROI showing Initial Payment Claimant is injured on 1/4/16, notifies his employer on 1/5/16 of the injury and disability. The employer advises the claim administrator (carrier/TPA) of the injury on 1/11/16. The Board assembles the case on 1/6/16 and indexed the file on 1/8/16. The claimant loses time from work due to his injury from 1/5/16 to 1/29/16 returning to work on 2/1/16. Carrier is required to pay and report per WCL § 25(1)(c) 18 days from disability and 10 days from employer knowledge. Date of Disability is 1/5/16 + 18 days = 1/23/16 To determine employer knowledge we take the earliest of Date employer had knowledge of injury - 1/5/16 Date employer had knowledge of Disability – 1/5/16 Indexing date – 1/8/16 Assembly date – 1/6/16 Earliest of the four is 1/5/16 which is the date the employer had knowledge. 1/5/16 + 10 days = 1/15/16 The greater of the two is 1/23/16 which is a Saturday, so the due date of the SROI showing initial payment is Monday 1/25/16. 7

October 15, 2021 Scenario 8 SROI showing Initial Payment using Initial vs Current Date of Disability Claimant is injured on 1/4/16, notifies his employer on 1/5/16 of the injury and disability. The employer advises the claim administrator (carrier/TPA) of the injury on 1/11/16. The Board assembles the case on 1/6/16 and indexed the file on 1/8/16. The claimant loses time from work due to his injury from 1/5/16 to 1/7/16 returning to work on 1/8/16. Claimant then goes back out of work on 1/25/16 and returns to work on 3/1/16 If Initial Date Disability Began (DN 0056) and Current Date Disability Began (DN 0144) are present, and the Initial Return to Work Date (DN 0068) is less than or equal to 7 days then Current Date of Disability (DN 0041) is used. Initial Date of Disability is 1/5/16 Initial Return to work is 1/7/16 The lost time is less than 7 days, therefore current date of disability is used. Current Date Disability Began is 1/25/16 Date of Disability is 1/25/16 + 18 days = 2/12/16 To determine employer knowledge we take the earliest of Date employer had knowledge of injury - 1/5/16 Date employer had knowledge of Disability – 1/5/16 Indexing date – 1/8/16 Assembly date – 1/6/16 Earliest of the four is 1/5/16 which is the date the employer had knowledge 1/5/16 + 10 days = 1/15/16 The SROI showing Initial Payment would be due by 2/12/16 which is the greater of the two dates. 8

October 15, 2021 9 MONITORING COMPLIANCE Timeliness of SROI showing Initial Payment of Compensation 9

October 15, 2021 10 Monitoring Compliance Penalty for Late SROI showing Initial Payment of Compensation WCL § 25(1) When No Controversy: Except in those cases when compensation is controverted, payment without an award of the Board must be made and the employer or carrier shall immediately notify the chair in accordance with a form prescribed by him, that the payment of compensation has begun. � Pay and Report to the Chair within 18 days of disability or 10 days after employer knowledge “promptly and in like manner as wages and without waiting for an award by the Board” [c]. SROI is not timely: � If the received date is more than 18 calendar days from Initial Date Disability Began (DN 0056) or Current Date Disability Began (DN 0144); and is � More than 10 calendar days from Date Employer Had Knowledge, whichever is greater. (18/10) 10

October 15, 2021 11 Monitoring Compliance Penalty for Late SROI showing Initial Payment of Compensation Penalties: WCL § 25 (3)(e) If the carrier or employer fails to file a notice or report requested or required by the Board or otherwise required within the specified time period or within 10 days if no time period is specified, the Board may impose a $50 penalty. Performance Standards: The penalty under § 25(3)(e) will not be imposed as long as a carrier meets the below performance standards set per quarter. If the performance standard is met per quarter your § 25(3)(e) penalty will be waived. � 1 st Quarter 2017 - 70% � 2 nd Quarter 2017 - 75% 11 � 3 rd Quarter 2017 - 80% � 4 th Quarter 2017 - 85%

October 15, 2021 12 Performance Standards 2015 Timely FROI Timely SROI Timely Controversy 2016 2017 2018 4 th Qtr 1 st Qtr 2 nd Qtr 3 rd Qtr 4 th Qtr 1 st Qtr 70% 75% 80% 85% 85% 70% 75% 80% 85% Quarter Penalized Quarter Not Penalized 12

October 15, 2021 13 HOW WE ARE MEASURING Timeliness of Initial Payment and Installment of Compensation 13

October 15, 2021 14 How We Are Measuring Timeliness of the Initial Payment and Installment of Compensation Timeliness of Initial Payment Enforcement of the 18/10 Day Rule defined in WCL Section 25(1)(c): If the employer or insurance carrier does not controvert the injured worker’s right to compensation such employer or insurance carrier shall, either on or before the 18 th day after disability, OR within 10 days after the employer first has knowledge of the alleged accident, whichever period is the greater, begin paying compensation…. Timeliness of Installment of Compensation: Enforcement of the 18/10 + 25 Day Rule defined in WCL Section 25(1)(e): If the employer or insurance carrier shall fail to pay any installments of compensation within twenty-five days after the same become due, there shall be paid by the employer or, if insured, its insurance carrier, an additional amount of twenty percent of the compensation then due which shall accrue for the benefit of the injured worker or his or her dependents and shall be paid to him or her or them with the compensation, unless such delay or default is excused by the board upon the application of the employer or insurance carrier upon the ground that owing to conditions over which the employer or insurance carrier had no control, such payment could not be made. 14

October 15, 2021 How We Are Measuring Determination of Dates Used for Measurements Employer Knowledge Date To Determine Employer Knowledge Date — the Board will use the earliest date of Date Employer Had Knowledge of the Injury (DN 0040), Date Employer Had Knowledge of Disability (DN 0281), Assembly Notice Date, Indexing Notice Date. Initial vs Current Date Disability Began If Initial Date Disability Began (DN 0056) and Current Date Disability Began (DN 0144) are present, and the Initial Return to Work Date (DN 0068) is less than or equal to 7 days then Current Date of Disability (DN 0144) is used. Claim Administrator Knowledge Date To determine Claim Administrator Knowledge Date the Board will use the earliest date of Date Claim Administrator Had Knowledge of the Injury (DN 0041), Assembly Notice Date, Indexing Notice Date. 15 15

Scenario October 15, 2021 16 Timeliness of Initial Payment Claimant is injured on 1/4/16, notifies his employer on 1/5/16 of the injury and disability. The employer advises the claim administrator (carrier/TPA) of the injury on 1/11/16. The Board assembles the case on 1/6/16 and indexed the file on 1/8/16. The claimant loses time from work due to his injury from 1/5/16 to 1/29/16 returning to work on 2/1/16. Carrier is required to pay and report per WCL § 25(1)(c) 18 days from disability and 10 days from employer knowledge. The Board is not allowed to issue a penalty for not making a timely first payment per § 25(2)(a) which states: When a carrier fails to file a notice of controversy or begin payment within the prescribed period or within 10 days of claims administrator knowledge (whichever period is greater) Date of Disability is 1/5/16 + 18 days = 1/23/16 To determine employer knowledge we take the earliest of Date employer had knowledge of injury - 1/5/16 Date employer had knowledge of Disability – 1/5/16 Indexing date – 1/8/16 Assembly date – 1/6/16 Earliest of the four is 1/5/16 which is the date the employer had knowledge - 1/5/16 + 10 days = 1/15/16 Date claim administrator had knowledge 1/6/16 + 10 days = 1/16/16 The first payment is not penalized if paid by 1/23/16 the greater of the three, which is a Saturday, so the payment is not penalized if paid by Monday 1/25/16. 16

October 15, 2021 Scenario 17 Timeliness of Installment Payment Claimant is injured on 1/4/16, notifies his employer on 1/5/16 of the injury and disability. The employer advises the claim administrator (carrier/TPA) of the injury on 1/11/16. The Board assembles the case on 1/6/16 and indexed the file on 1/8/16. The claimant loses time from work due to his injury from 1/5/16 to 1/29/16 returning to work on 2/1/16. WCL Section 25(1)(e): If the employer or insurance carrier shall fail to pay any installments of compensation within twenty-five days after the same become due (18/10 per § 25(1)(c)) Date of Disability is 1/5/16 + 18 days = 1/23/16 To determine employer knowledge we take the earliest of Date employer had knowledge of injury - 1/5/16 Date employer had knowledge of Disability – 1/5/16 Indexing date – 1/8/16 Assembly date – 1/6/16 Earliest of the four is 1/5/16 which is the date the employer had knowledge 1/5/16 + 10 days = 1/15/16 The greater of the two is 1/23/16 + 25 days = 2/17/16 The installment payment is not penalized if paid by 2/17/16. 17

October 15, 2021 18 MONITORING COMPLIANCE Timeliness of Initial Payment and Installment of Compensation 18

October 15, 2021 19 Monitoring Compliance Penalty for Late Initial Payment of Compensation WCL § 25(1) When No Controversy: Except in those cases when compensation is controverted, payment without an award of the Board must be made. � (2)(a) When a carrier fails to file a notice of controversy or begin payment within the prescribed period or within 10 days of claims administrator knowledge (whichever period is greater), the Board may impose a $300 penalty payable to the claimant, in addition to any other penalty. Payment is not timely: � If Benefit Payment Issue Date (DN 0192) is more than 18 calendar days from Initial Date Disability Began (DN 0056) or Current Date Disability Began (DN 0144); and is more than 10 calendar days from Date Employer Had Knowledge, and is more than 10 calendar days from Date Claims Administrator Had Knowledge, whichever is greater. (18/10/10) 19

October 15, 2021 20 Monitoring Compliance Penalty for Late Installment Payment of Compensation WCL § 25(1) When No Controversy: Except in those cases when compensation is controverted, payment without an award of the Board must be made. � (1)(e) When a carrier shall fail to pay any installment of compensation within 25 days after said installment became due, a penalty of 20% of compensation then due plus $300 shall be imposed payable to claimant. Payment is not timely: � If Benefit Payment Issue Date (DN 0192) is more than 18 calendar days from Initial Date Disability Began (DN 0056) or Current Date Disability Began (DN 0144); and is more than 10 calendar days from Date Employer Had Knowledge, whichever is greater plus an additional 25 calendar days. (18/10 +25) 20

October 15, 2021 21 History of SROI Filings 21 Total Transactions Received Timely SROI Showing Initial Payment Timely First Payment Timely Installment 4 th Quarter 2015 13, 590 40. 9% 54. 7% 75. 3% 1 st Quarter 2016 12, 344 48. 2% 61. 4% 79. 3% 2 nd Quarter 2016 18, 534 49. 3% 75. 1% 86% 3 rd Quarter 2016 19, 074 47. 9% 73% 86. 3%

October 15, 2021 Ways to Improve Timely SROI showing Initial Payment Timely Installment 22 22

October 15, 2021 SROI EP � Carriers are not filing the SROI EP when an employer is paying wages. � Instead Carriers are filing the SROI IP when an employer has stopped paying wages and carrier has picked up payments. Thus, the SROI IP is the first SROI the Board receives and is therefore the SROI that is measured for timely filing and timely first payment and is often late. � The SROI EP should be filed with the Board when an injured worker is losing compensable time from work and the employer is paying wages. � The SROI EP is an automatic timely first payment. � The SROI EP will be measured for timeliness of the filing using the 18/10 rule. � Effective 3/28/16 carriers can now file the SROI EP with the Agreement to Compensate Code of “W” without liability. There is no longer the need to file the SROI PD in this situation. 23 23

October 15, 2021 24 SROI IP � The SROI IP should be filed with the Board within the 18/10 rule when the initial payment is being made and the employer is not paying wages. � Claim Type Code: As of 11/17/16 the claim type code on a SROI IP should always be an I Indemnity or L- became Lost Time. � When a SROI IP is filed and not completed accurately, it leads to late filings. � Initial Date Disability Began/Current Date Disability Began – If the Initial Date Disability Began (DN 0056) and the Initial Return to Work Date (DN 0068) is less than or equal to 7 days and the injured worker loses further time from work, the carrier should enter a Current Date of Disability (DN 0144), the Board would then measure 18 days from the Current Date of Disability (DN 0144). 24

October 15, 2021 25 SROI PY � SROI PY should be used for a one time payment with no continuing compensation payments such as reporting payment of a Section 32, reporting payment of a SLU and payment of penalties. � SROI PY is being used improperly as the initial SROI showing initial payment within 18/10 instead of using the SROI IP. � SROI PY will be measured for timeliness of initial payment and timeliness of filing if the SROI PY is showing a payment of indemnity and the Benefit Type Code (DN 0085) is anything other than 030 Permanent Partial Schedule (SLU), 090 Permanent Partial Disfigurement (facial) or 5 xx Lump Sum/Settlement. � If the SROI PY is the first SROI received showing the initial payment of compensation, a Benefit Payment Date is not a requirement. If the Benefit Payment Date is not present, this filing will be considered one day late. The carrier will have to request review, produce proof of the payment date and file the SROI 02 making the change. To avoid this scenario, use the IP opposed to the PY. 25

October 15, 2021 26 SROI PD � SROI PD should be filed if the injured worker has compensable lost time and the carrier is not making payment and has not controverted (FROI/SROI 04) the claim. � SROI PD should only be used in very limited circumstances such as: • when the carrier has an IME or medical report indicating no disability, • a different site of injury than originally reported, • when claimant fails to appear for carrier scheduled appointment per § 13 -a(3) or scheduled IME within the 7 day waiting period, • where there is a medical report in the file that indicates the claimant will be out of work for seven days or less and there is no subsequent medical report of disability beyond the waiting period, • in the rare instance where the medical evidence indicates a partial disability and the claimant has refused light duty, • in the rare instance where the claimant is losing time due to injuries on multiple claims and carrier is paying on one claim only, pending apportionment. 26

October 15, 2021 SROI PD � It has been noticed that carriers are using the denial reason narrative on the SROI PD improperly. Some improper reasons being used are: • No lost time beyond seven days • No medical evidence of disability • No prima facie medical • Employer paying wages � SROI PD is filed prior to a SROI IP or any SROI showing the initial payment of indemnity: • SROI showing the initial payment is not measured. • The SROI PD is reviewed manually, if the SROI PD is found to be used improperly then all penalties that would have been issued through Payor Compliance will be assessed by an Administrative Decision. 27 27

October 15, 2021 Type of Loss Code Incorrect Type of Loss Codes DN 0290 Type Of Loss Code – A code indicating the type of loss being reported: 01 = Traumatic Injury – An injury that is traceable to a definite accident during the worker’s present employment. 02 = Occupational Disease – An injury caused by exposure to a disease producing agent in the worker’s occupational environment. 03 = Cumulative Injury (other than disease) – An injury having occurred from or aggravated by, a repetitive employment activity. Type of loss codes 02 and 03 are excluded from measurement. However, all filings made with Type of Loss Code 02 or 03 will be scrutinized manually. In the event that it is determined the Type of Loss Code was used improperly, the Carrier will be notified to file their SROI 02 making the necessary correction. Once the form is corrected the initial filing will be measured for timeliness for all categories. 28 28

October 15, 2021 No Medical Proper E-Claims Filing 29 29

October 15, 2021 30 Proper E-Claims Filing Payor Options When No Medical Present and the employer has reported a work related accident or injury that is expected to result in compensable lost time: Option: When there is no medical evidence in the file, the carrier may pay at the tentative mild rate pending receipt of medical from the claimant’s treating provider. Option: The carrier may make payment without prejudice (§ 21 -a) by filing their SROI IP with agreement to compensate code without liability (DN 0075) Option: When no medical evidence is produced within 48 hours of treatment, the carrier may transfer the claimant’s care per 13 -a (3) to an authorized treating provider in order to obtain an opinion as to degree of disability and pay benefits in accordance with the physician’s opinion. 30

October 15, 2021 31 Proper E-Claims Filing Option: When there is no medical evidence in the file, the carrier may choose to obtain an IME per § 137 of the Workers Compensation Law. Option: The employer/carrier may choose to use a Preferred Provider Organization (PPO) in accordance with Article 10 -A and 12 NYCRR § 325 -8. 1 to 325 -8. 6, which requires treatment by PPO providers for the first thirty days. Option: When no medical evidence is sent to the Board file within 30 days from the date the employer had knowledge of the date of disability (DN 0281) the carrier may suspend benefits, as the inference of disability contained in the employer’s initial report lasts only a reasonable time. The carrier may, of course, also suspend benefits anytime it receives a C-11 indicating the claimant has RTW. 31

October 15, 2021 Request for Review Upheld, Withdrawn or Hearing 32 32

October 15, 2021 33 Request for Review § 25(3)(e), § 25(2)(a) and § 25(1)(e) Penalty Process � Reports are posted to the Board’s web site at www. wcb. ny. gov on the 15 th of the following month, or next business day after the quarter being measured using the Payor Compliance web application. � Proposed Penalty letters or Met Performance letters are mailed the same day the reports are posted, but are postdated 2 days later. � The Carrier/TPA will have 30 days from the date of the proposed penalty notice to review the cases that are considered late and request review. � The Carrier/TPA will request review of the case(s) electronically on the Boards webpage using the Payor Compliance application. � The Carrier/TPA will need to state the reason for their request for review (text box) and will be able to upload and attach proof to their request. � After 30 days has lapsed, the Board will review the Carriers/TPA’s request for review and determine whether the penalty should be upheld or withdrawn. 33

October 15, 2021 Penalty Withdrawn If the penalty is withdrawn for a § 25(3)(e) penalty, the Carrier/TPA will be able to see on the Boards webpage that their penalty amount and percentage of timely filings for that quarter has been updated with the new figures. � If withdrawing a penalty results in the carrier meeting the performance standard for § 25(3)(e) penalties, the carrier will be notified that they have met the performance standard and that additional penalties are waived. � Wait for invoice to make payment of penalty. If the penalty is withdrawn for a § 25(2)(a) or § 25(1)(e) penalty, the Carrier/TPA will receive an Administrative Decision advising of the withdrawal. 34 34

October 15, 2021 35 Penalty Upheld Carrier/TPA will receive an Administrative Decision (AD) advising of so for all penalties issued. The Carrier/TPA has 30 days to object to the Administrative Decision electronically. � The Carrier/TPA will need to state the reason for their objection (text box) and will be able to upload and attach proof to their request. � Objections to this decision made without reasonable grounds are subject to additional penalties under WCL § 114 -a(3). § 25(3)(e) penalties � If objection to AD is related to a § 25(3)(e) penalty, case moves to the hearing process. § 25(2)(a) & § 25(1)(e) penalties � If withdrawn – AD issued to Carrier/TPA advising of withdrawal. � If upheld – second AD will be issued to all parties (carrier, TPA, claimant attorney) awarding the penalty as these penalties are payable to the claimant. 35

October 15, 2021 36 Penalty Upheld All parties have 30 days to object to the second Administrative Decision. § 25(2)(a) penalties � Carriers/TPA’s must object electronically. ● At the time of objection the carrier/TPA will be required to either waive or not waive their right to hearing. • • Waive right to hearing – Proposed Decision is issued with outcome Not waive their right to hearing – Case goes to Hearing Process ● Claimant/Claimant attorney can object by e-mail or in writing. • If objection received case goes to hearing process. § 25(1)(e) penalties � Carriers/TPA’s must object electronically. � Claimant/Claimant attorney can object by e-mail or in writing. ● If objection received case goes to hearing process. 36

October 15, 2021 Hearing Process � Hearings will be done by Phone � Carrier/TPA will be required at the time of their objection to give the representatives name and phone number they can be reached at. � Hearing notice will be sent to the appropriate parties with the date and time of the hearing. � Hearing notice will list cases that will be heard. � The sole issue addressed at such hearings will be the penalty issue raised in the initial objection. � Hearings will be set by carrier, not by claim, to address all outstanding penalties upheld for that category per quarter. � If you wish to appeal the hearing or object to the Proposed Decision you must do so by filing an RB-89 using the current process. 37 37

October 15, 2021 Invoice Process When You Should Pay 38 38

October 15, 2021 Invoice Process � Invoices are only sent on penalties payable to the Board (§ 25(3)(e)). � If 30 days lapses from receipt of the proposed penalty notice and no request for review is received an invoice will be sent to the carrier advising of the penalty amount and the due date of payment. � Once the Board has reconciled all claims for that quarter in which a review was requested, AD was issued or Hearing held, the Carrier will receive an invoice from the Board with the final penalty amount. � Payment of the penalty is required 10 days from the invoice notice. 39 39

October 15, 2021 Invoice Process � If withdrawing a penalty results in the carrier meeting the performance standard, the carrier will be notified that they have met the performance standard and that additional penalties are waived. No invoice will be sent. � Every proposed penalty notice and invoice have a penalty ID, that ID advises the Board of the quarter and category of the penalty in which to properly apply payment. � The penalty ID should be placed on all checks sent to the Board. � The Board would prefer one check for the entire payment for that quarter for that category. 40 40

October 15, 2021 41 Invoice Notice sent Through WCB Notifications 10/5/16 Payment of Penalties issued Through Payor Compliance: Penalties levied in accordance with WCL § 25(3)(e) for failure to make a timely filing of a first report of injury, subsequent report of injury showing initial payment and timely controversy are to be paid to the Board within 10 days of receipt of the invoice and not the proposed penalty letter. Payment received by the Board prior to an invoice being sent may result in an incorrect application of that payment or potentially even the Board returning your check if there is no open receivable for it to be applied to. Please refrain from making payment of these penalties until you are in receipt of the invoice advising of the actual amount owed. Invoices are released the first week of every month, as long as all cases for that carrier for that quarter have been reconciled. Please return the bottom half of the invoice along with placing the penalty ID and carrier code on the check. 41

October 15, 2021 SROI Reports 42 42

October 15, 2021 Review of Reports Associated to SROI 43 43

October 15, 2021 AD Objection 44 44

October 15, 2021 45 For Questions or More Information: Denise Hughes, Monitoring Program Manager Monitoring@wcb. ny. gov Visit Our Website: wcb. ny. gov/content/main/monitoring/overview. jsp 45