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WORKERS’ WORKERS’ COMPENSATION COMPENSATION
PROGRAM: THE ROLE PROGRAM: THE ROLE OF THE ON-SITE OF THE ON-SITE
COUNTY COUNTY REPRESENTATIVESREPRESENTATIVES
TONY TARASTONY TARAS(800) 782-5888 ext 1678(800) 782-5888 ext [email protected]
County Code 5.31.050Workers’ Compensation
System
1. Report, investigate, and adjust claims.
2. Determine compensability and pay benefits.
3. Collect and report statistical data.4. Establish and review reserves.5. “Control…workers’
compensation costs consistent with full provision of benefits under the law.”
TPA CONTRACTS –TECHNICAL EXHIBIT I
WORKERS’ COMPENSATION PROGRAM
“The primary objective of this program is to provide all workers’ compensation benefits required under State law to injured County employees on a timely basis, at the least possible cost to the County.”
TRISTAR – RANCHO TRISTAR – RANCHO (UNIT 1)(UNIT 1)
MANAGER: KAREN SATURDAYMANAGER: KAREN SATURDAY (800) 782-5888 ext 1683(800) 782-5888 ext 1683
MONITORS: MARK LEBLANCMONITORS: MARK LEBLANC (800) 782-5888 ext 1648(800) 782-5888 ext 1648
TONI VUTONI VU (800) 782-5888 ext 1769(800) 782-5888 ext 1769 [email protected] [email protected]
TRISTAR – SANTA ANA TRISTAR – SANTA ANA (UNIT 2)(UNIT 2)
MANAGER: OLA OSIFESOMANAGER: OLA OSIFESO (800) 782-5888 ext 1152(800) 782-5888 ext 1152
[email protected]@tristargroup.net
MONITOR: ROSE BLOOMMONITOR: ROSE BLOOM (800) 782-5888 ext 1676(800) 782-5888 ext 1676
[email protected]@ceo.lacounty.gov
INTERCARE (UNIT 3)INTERCARE (UNIT 3)
MANAGER: KATHLEEN BURRISMANAGER: KATHLEEN BURRIS (866) 221-2968 ext 430(866) 221-2968 ext 430
[email protected]@intercareins.com
MONITORS: JOE CARRILLOMONITORS: JOE CARRILLO (866) 221-2968 ext 422(866) 221-2968 ext 422
[email protected]@ceo.lacounty.gov
PAM KENNEDYPAM KENNEDY (866) 221-2968 ext 421(866) 221-2968 ext 421 [email protected]@ceo.lacounty.gov
AIMS (UNIT 4)AIMS (UNIT 4)
MANAGER: CHERYL AGEEMANAGER: CHERYL AGEE
(661) 705-2908(661) 705-2908
[email protected]@aims4claims.com
MONITOR: ERNIE ROMOMONITOR: ERNIE ROMO
(661) 705-2905(661) 705-2905
[email protected]@ceo.lacounty.gov
ON-SITE COUNTY REPRESENTATIVE
““The Quality Assurance Evaluator is a The Quality Assurance Evaluator is a County employee designated as an agent County employee designated as an agent for the County responsible for monitoring for the County responsible for monitoring the Contractor’s performance, approving the Contractor’s performance, approving over limit payments, advising and training over limit payments, advising and training third party administrator staff in County third party administrator staff in County payroll systems and other County payroll systems and other County procedures.” At times this employee may procedures.” At times this employee may be referred to as the On-Site County be referred to as the On-Site County Representative (OSCR).Representative (OSCR).
DUTIES OF THE OSCRDUTIES OF THE OSCR
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 OSCRDUTIES OF THE OSCR
Assist TPA staff on balancing of Assist TPA staff on balancing of complex casescomplex cases
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 OSCRs, CEO RTW quarterly with OSCRs, CEO RTW personnel, Departmental RTW personnel, Departmental RTW personnel, Loss Control, and County personnel, Loss Control, and County Counsel.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 TPAs, OSCRs, Get input from your TPAs, OSCRs,
and Counsel.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 Information about any RTW efforts that
have been madehave been made Information about any disciplinary action Information about any disciplinary action
being taken against the injured worker being taken against the injured worker (unless confidential)(unless confidential)
Information about any other action the Information about any other action the injured worker is taking against the County injured worker is taking against the County (unless confidential)(unless confidential)
Type of retirement planType of retirement plan Out of service date and termination reason, Out of service date and termination reason,
if anyif 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
Additional questions on:Additional 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
TEMPORARY WORK RESTRICTION LETTERS
Issued based on temporary work restrictions provided by primary treating physician, AME, and/or State Panel QME prior to finding of permanent and stationary.
Sometimes referred to as interim or transitional. There may be multiple versions due to the
changes in the injured worker’s medical condition.
The TPA is required to issued the letter within 10 days of receipt of applicable medical documentation.
PERMANENT WORK RESTRICTION LETTERS
(PRIOR TO SETTLEMENT) Based on permanent and stationary finding
of the primary treating physician, AME, and/or State Panel QME.
There may be more than one version based on differing medical opinions.
The TPA is required to issue the letter within 10 days of receipt of applicable permanent and stationary medical reports.
The 15% increase/decrease under LC 4658 is usually determined at this juncture.
PERMANENT WORK RESTRICTION LETTERS (AFTER SETTLEMENT)
Based on work restrictions agreed upon by parties and included in settlement documents.
The TPA is required to issue letter within 10 days of receipt of settlement documents.
In most cases, this is the final work restriction letter the TPA will issue on an individual claim.
QUESTIONS?QUESTIONS?
