WORKERS’ WORKERS’ COMPENSATION: COMPENSATION:

THE ON-SITE COUNTY THE ON-SITE COUNTY REPRESENTATIVES/REPRESENTATIVES/INJURY REPORTINGINJURY REPORTING

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Joe CarrilloWorkers’ Compensation

ProgramCEO Risk Management

Branch

County Code 5.31.050Workers’ Compensation

System1. 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.”

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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.”

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TRISTAR – RANCHO TRISTAR – RANCHO (UNIT 1)(UNIT 1)

MANAGER: JAMES SOTOMANAGER: JAMES SOTO (800) 782-5888 (800) 782-5888

james.soto@tristargroup.netjames.soto@tristargroup.netMONITOR: TONI VUMONITOR: TONI VU (800) 782-5888 ext 1679(800) 782-5888 ext 1679 tvu@ceo.lacounty.gov tvu@ceo.lacounty.gov

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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

ola.olifeso@tristargroup.netola.olifeso@tristargroup.net

MONITOR: ROSE BLOOMMONITOR: ROSE BLOOM (800) 782-5888 ext 1676(800) 782-5888 ext 1676

rbloom@ceo.lacounty.govrbloom@ceo.lacounty.gov

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INTERCARE (UNIT 3)INTERCARE (UNIT 3)

MANAGER: LANAI PHOUNG PHUNMANAGER: LANAI PHOUNG PHUN (866) 221-2968 ext 430(866) 221-2968 ext 430

lphoungphunlphoungphun@intercareins.com@intercareins.com

MONITORS: JOE CARRILLOMONITORS: JOE CARRILLO (866) 221-2968 ext 422(866) 221-2968 ext 422

jcarrillo@ceo.lacounty.govjcarrillo@ceo.lacounty.gov PAM KENNEDYPAM KENNEDY (866) 221-2968 ext 421(866) 221-2968 ext 421 pkennedy@ceo.lacounty.govpkennedy@ceo.lacounty.gov

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AIMS (UNIT 4)AIMS (UNIT 4)

MANAGER: CHERYL AGEEMANAGER: CHERYL AGEE (661) 705-2908(661) 705-2908

cagee@aims4claims.comcagee@aims4claims.com

MONITOR: ERNIE ROMOMONITOR: ERNIE ROMO (661) 705-2905(661) 705-2905

eromo@ceo.lacounty.goveromo@ceo.lacounty.gov

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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).

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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

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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

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

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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.

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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”!

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CLAIM REVIEWSCLAIM REVIEWS

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

been madebeen made 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

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WORK WORK RESTRICTION RESTRICTION

LETTERSLETTERS

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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.

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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.

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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.

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QUESTIONS?QUESTIONS?

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Overview of Overview of Workers’ Workers’

Compensation andCompensation andInjury ReportingInjury Reporting

RETURN TO WORK 101RETURN TO WORK 101INJURY REPORTING INJURY REPORTING

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Emergency injury reportedEmergency injury reported

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Emergency injury reported Emergency injury reported cont…cont…

Once the situation is stable, you should:Once the situation is stable, you should:

1.1. Provide a DWC1 Claim Form to employee, complete Provide a DWC1 Claim Form to employee, complete the Employer’s Report of Injury (5020) and call into the the Employer’s Report of Injury (5020) and call into the Toll-Free number within 24 hours.Toll-Free number within 24 hours.

2.2. Complete the Job Description form.Complete the Job Description form.

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WORKERS’ COMPENSATION CLAIM FORM (DWC 1)

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EMPLOYER’S REPORT OF OCCUPATIONAL INJURY/ILLNESS (5020 FORM)

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JOB DESCRIPTION FORM

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JOB DESCRIPTION FORM

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NON-EMERGENCY INJURY NON-EMERGENCY INJURY REPORTEDREPORTED

If Employee Declines Treatment:If Employee Declines Treatment:

1.1. Employee must complete the Employee’s Statement Employee must complete the Employee’s Statement Declining Treatment form. A copy of the form must be Declining Treatment form. A copy of the form must be sent to the RTW Coordinator or Personnel.sent to the RTW Coordinator or Personnel.

2.2. Employee must sign Receipt of Employee Packet, and be Employee must sign Receipt of Employee Packet, and be given the packet.given the packet.

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Employee’s declining medical Employee’s declining medical treatment FORMtreatment FORM

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Receipt of employee packetReceipt of employee packet

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Employee seeks treatmentEmployee seeks treatment

Review the Employee’s Guide for Injury Reporting with Review the Employee’s Guide for Injury Reporting with the employee.the employee.

Complete the Injury Reporting forms with the employee. Complete the Injury Reporting forms with the employee. The packet must contain the four forms below: The packet must contain the four forms below:

1.1. The completed Treatment Referral SlipThe completed Treatment Referral Slip

2.2. The completed Treating Physician’s letter (for physical injuries only)The completed Treating Physician’s letter (for physical injuries only)

3.3. A copy of the blank Patient Status ReportA copy of the blank Patient Status Report

4.4. A copy of the completed Job Description should be included in the A copy of the completed Job Description should be included in the Medical Provider Packet.Medical Provider Packet.

Send the four documents with the employee to theSend the four documents with the employee to thePre-designated physician or ITC, as applicable.Pre-designated physician or ITC, as applicable.

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Treatment referral slip FORMTreatment referral slip FORM

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Treating physician’s letter Treating physician’s letter (Physical injuries only)(Physical injuries only)

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Patient status report FORMPatient status report FORM(Physical injuries only)(Physical injuries only)

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EMPLOYEE’S REPORT OF ACCIDENT FORMEMPLOYEE’S REPORT OF ACCIDENT FORM

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EMPLOYEE SEEKS TREATMENT EMPLOYEE SEEKS TREATMENT CONT...CONT...

Ask the employee if they have Pre-designated a treating Ask the employee if they have Pre-designated a treating physician.physician.

If they have not, send them to the Medical Provider If they have not, send them to the Medical Provider Network (MPN) Initial Treatment Center (ITC). Network (MPN) Initial Treatment Center (ITC).

A list of those centers can be obtained on the County’s A list of those centers can be obtained on the County’s MPN website at:MPN website at:http://ceo.lacounty.gov/mpnhttp://ceo.lacounty.gov/mpn

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PREDESIGNATION OF PERSONAL PHYSICIAN FORM

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EMPLOYEE SEEKS TREATMENT EMPLOYEE SEEKS TREATMENT CONT…CONT…

Provide the DWC1 Claim Form to the employee and Provide the DWC1 Claim Form to the employee and complete the Employer’s Report (5020) form. The complete the Employer’s Report (5020) form. The injury must be called into the injury must be called into the Toll-FreeToll-Free number within number within 24 hours upon notice of the injury.24 hours upon notice of the injury.

Call the Toll-Free number and report the injury.Call the Toll-Free number and report the injury.

In some departments, the main RTW Unit staff calls In some departments, the main RTW Unit staff calls in the injury, in others the supervisor or location in the injury, in others the supervisor or location designee calls it in.designee calls it in.

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MPN Initial Treatment Centers (ITC)MPN Initial Treatment Centers (ITC)

If Employee has not Pre-designated their personal If Employee has not Pre-designated their personal treating physician, the work location Supervisor or treating physician, the work location Supervisor or designee must direct them into the County’s Medical designee must direct them into the County’s Medical Provider Network (MPNs), via an Initial Treatment Provider Network (MPNs), via an Initial Treatment Center (ITC).Center (ITC).

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Review of employee responsibilitiesReview of employee responsibilities

Complete DWC-1 Employee Claim FormComplete DWC-1 Employee Claim Form

Complete Employee’s Report of AccidentComplete Employee’s Report of Accident

Return the Completed forms to their supervisor/including Return the Completed forms to their supervisor/including all Medical Certifications from the treating physicianall Medical Certifications from the treating physician

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Questions???Questions???

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