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Topic: REVIEW OF PERFORMANCE OF WORKERS' Date Issued: June 30, 1994

COMPENSATION CLAIMS ADMINISTRATOR Date Revised:

Section: WORKERS' COMPENSATION

Number: XXI.4

PURPOSE:

To oversee the work of the contractor administering the County's self-in-

sured Workers' Compensation program to ensure that they properly carry out

State legal requirements, that eligibility for benefits is determined

promptly and appropriately, that benefits are provided in a timely manner,

and that the County is not exposed to penalties or fines.

LEGAL BASIS:

Division 4 of the Labor Code of the State of California

POLICY:

The County is licensed by the State of California to be self-insured for

providing Workers' Compensation benefits to its employees. The County is

ultimately responsible to the State for the actions of the claims adminis-

trator, which is acting on behalf of the County in providing State-mandated

benefits. If the program is administered improperly, the County could lose

its Self Insurance License. Poor decisions by the claims administrator can

cost the County money if benefits are provided inappropriately. Unsupport-

ed denial of benefits could subject the County to State fines and penal-

ties. Lack of control and review of medical treatment can also cost the

County needless expense. Due to the potential for serious consequences,

the performance of the claims administrator is constantly monitored to

catch and correct problem areas.

PROCEDURE:

I. Risk Management performs the following activities in assessing and

directing the work of the claims administrator:

A. Reviews medical reports and correspondence from claims examiners

and attorneys to monitor the handling of claims

XXI.4

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COMPENSATION CLAIMS ADMINISTRATOR

B. Confers with claims examiners on handling of individual claims, and

approves acceptance of claims; authorizes delay and investigation of

questionable claims

C. Directs the handling of complex claims and authorizes settlement

negotiation

D. Reviews monthly claims loss runs and narrative status reports

provided by claims examiners on all open indemnity claims (claims

involving lost time or medical treatment over $500)

E. Confers with claims examiners on strategies for moving cases to

closure

F. Approves assignment of cases to attorneys and pulling and reas-

signment of cases where the attorney's handling has been weak or

ineffective

G. Selects cases for review at quarterly claims review meetings and

conducts meeting with claims administrator staff, Risk Manager,

County Counsel, and Occupational Health Physician, where handling

of difficult cases is discussed and strategies developed to move

cases to closure.

II. Audit of Claims Administrator

A. Periodically, Risk Management contracts with an outside auditor

to conduct a comprehensive audit on the claims administrator's

handling of a selection of open and closed claims. The Workers'

Compensation Program Manager follows up with the claims adminis-

trator to ensure that all problems identified in the audit are

corrected.

B. The State of California's Division of Workers' Compensation,

Office of Benefit Assistance and Enforcement also conducts peri-

odic audits of the claims administrator, and notifies the County

of any problem areas. The Risk Manager and Workers' Compensation

Program Manager work with the claims administrator in responding

to the State and following through on recommendations of the

auditor.

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