Insurer audit manual
Disclaimer This publication may contain work health and safety and workers compensation information. It may include some of your obligations under the various legislations that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate legislation. Information on the latest laws can be checked by visiting the NSW legislation website legislation.nsw.gov.au This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals or as a substitute for legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation. WorkCover NSW
Contents Introduction 2 Claims management audit criteria 2 WorkCover initiated audit 4 Insurer self-audit 4 Auditor qualification 4 Roles and responsibilities 4 Audit methodology 5 Audit planning 7 Audit outcome 8 Appendix A Insurer audit tool Appendix B Improvement plan template
Introduction The role of the WorkCover NSW (WorkCover) as the workers compensation regulatory body is to ensure insurers meet legislative requirements in the delivery of claims management services. It is also WorkCover s role to support insurers to achieve improved return to work outcomes for workers and employers through effective claims management. The purpose of the Insurer audit manual (catalogue no. WC01591) (the manual) is to describe the procedures WorkCover and insurers will use to evaluate compliance with the practices and principles of claims management, and to drive continuous improvement. When developing the manual, the following foundations were considered: the audit program should focus on a quality improvement approach rather than a compliance approach the audit tool should be consistent with legislative reforms and focus on recovery at work and work capacity the audit tool should reflect good claims management practice as well as efficient and effective process. This manual applies to all scheme agents, self insurers and specialised insurers who will be referred to collectively as insurers throughout the manual. Insurers must participate in the requirements outlined in the manual as per the scheme agent deed or self and specialised insurer licensing requirements. Claims management audit criteria There are 72 audit criteria in total, which are grouped into 14 specific elements. Audit elements Injury management and recovery at work assessment Injury management and recovery at work planning Injury management and recovery at work implementation Injury management and recovery at work finalisation Service provider management Liability determination Managing payments Wage reimbursement Claims estimation Work capacity Permanent impairment Work injury damages Commutations Information and records management. 2 WORKCOVER NSW
Claims management principles The claims management audit criterion has been designed with the intent of facilitating the application of claims management principles into the insurer s claims management processes. The application of these principles throughout the life of a claim aims to improve the outcome and experience for all stakeholders. Focus on work () activities are designed to facilitate recovery at work or a worker s capacity for work. Effective communication () transparent, regular and relevant communication from the notification of an injury to the close of a claim, to set clear expectations of the return to work outcomes and the roles and responsibilities of all parties communication is respectful, open and considerate of the workers and employers primary language, cultural background and literacy skills barriers are promptly addressed with the view to promote recovery at work relationships with all parties are built to achieve the best outcomes through negotiation and influence relationships are managed with a view to motivating and empowering all parties to accept their responsibilities as facilitators of recovery at work and capacity for work. Evidence based decisions () the issue or matter that requires a decision is determined on the basis of the best available evidence legislation and WorkCover guidelines are considered and applied where relevant information and evidence about the issue is gathered in a manner free of preference or prejudice the implications of a decision (including cost benefit, risk assessment and alternatives) are considered when faced with a choice, select the best option on the basis of the most logical, rational and reasonable outcome decisions are made and communicated within legislated timeframes identify escalation points for decisions that require higher authority levels or are potentially contentious. A tailored, cost effective approach () use adequate and appropriate assessment to achieve a return to work outcome according to the needs of the worker match service levels to claim needs match service costs to the range and extent of service provision determine strategies that are tailored to support the worker and employer to achieve a return to work outcome activities are coordinated and integrated. Timely intervention () attention and intervention is both prompt and appropriate to the needs of the worker and other key parties proactive management, including predicting and preparing for events that will have an impact on the worker s progress, to achieve a return to work outcome. Each criterion within the audit tool has been linked to one or more of the claims management principles. Upon completion of the audit, the results can be collated to identify potential systemic issues in relation to a specific principle. INSURER AUDIT MANUAL 3
WorkCover initiated audit WorkCover may conduct an audit of the insurer within each license or contract period. WorkCover may conduct additional audits where specific issues have been identified including but not limited to: low audit or self-audit scores verifying the implementation of improvement plans complaints received about the insurer significant changes to the insurer s claims management model. Insurer self-audit Self and specialised insurers Insurers are required to: Conduct annual self-audits in line with the requirements described in the manual and licensing requirements. This includes the use of the Appendix A Insurer audit tool. Note that a self-audit is not required to be conducted in the same financial year as a WorkCover initiated audit. Develop an improvement plan based on the results of the self-audit in line with the requirements outlined in this document. Implement the improvement plan as documented. Submit a copy of the self-audit to WorkCover in line with the licensing requirements. Submit a copy of the improvement plan to WorkCover, if requested to do so. Scheme agents Insurers are required to: TBD. Auditor qualification An audit must be conducted by a suitably qualified and experienced team or individual. It is expected that the team or individual completing the audit will include: a lead auditor who has successfully completed a formal auditor training course a team member who has a minimum five years recent experience within the workers compensation insurance industry. To ensure impartiality, audit team members should not evaluate case records with which they have been personally involved. Roles and responsibilities In addition to the requirements outlined in this manual, stakeholders also have the following responsibilities: The lead auditor will: select the audit team prepare the audit plan and communicate the plan to the insurer ensure the audit is conducted as outlined in this manual, unless deviation has been authorised by WorkCover 4 WORKCOVER NSW
make final decisions in regards to the scoring of criteria, where differences of opinion exist within the audit team ensure that the audit team s working papers adequately support the findings ensure that the audit report is accurate, objective, clear and timely. The audit team will: perform the audit, as per the audit plan, under the direction of the lead auditor collect and analyse relevant information, determine findings and summarise for the audit conclusions seek guidance from the lead auditor when required. The insurer will: allocate appropriate resources for the completion of the audits as outlined in this manual provide the audit team with access to case records and facilities appoint a designated person to form part of the WorkCover audit team ensure completion of the self-audit is conducted as outlined in this manual, unless deviation has been authorised by WorkCover implement strategies to ensure the integrity of the self-audit process. The Insurer-designated audit team member (WorkCover audit) will: provide the audit team with an overview of the case record and information management system be available to the WorkCover audit team during the audit to discuss all potential non-compliances and assist in the identification of further information for consideration provide additional support as required. WorkCover will: Review the manual as required, but no later than biennially to ensure currency and effectiveness of the manual and to incorporate any legislative amendments, changes to WorkCover guidelines and related publications. Audit methodology Audit tool The audit tool contains the criteria with which the audit must be conducted. Audit scope WorkCover may choose to limit the scope of the WorkCover initiated audit to specific elements of the Appendix A Insurer audit tool. Unless directed otherwise, insurers must conduct their self-audit using the Appendix A Insurer audit tool in its entirety. INSURER AUDIT MANUAL 5
Audit sample size The number of case records to be audited will be determined for each insurer according to the number of significant injury claims received in the preceding 18 months. The minimum number of case records for an audit was determined in consultation with Deloitte Touche Tohmatsu and is as follows: Claims range (number of significant injuries in preceding 18 months) Minimum sample size Less than 45 10 46 to 100 15 101 to 500 30 More than 500 45 Sample selection The case records to be audited will be a selected sample of claims with the intention of covering all elements included in the audit scope. Where appropriate and possible, the sample will reflect the types of business and company sites. Scoring When conducting an audit, the auditor will be required to make judgements as to whether the criteria have been met. The judgement is informed by evidence which verifies the appropriate application of claims management. The auditor must audit activities on the case record based upon the legislation and guidelines that were in effect at the time the activity was conducted, where applicable. The scoring options of each audit criteria are: compliance non-compliance, or not applicable. A compliance will provide a score of 1, whilst a non-compliance will be scored as 0. Where an audit criteria may contain multiple components, the findings must be compliant with all components of the criteria to receive a compliance score. Otherwise a non-compliance should be scored. The audit can be scored by entering the results into the Audit results spreadsheet. This spreadsheet is an excel document which will calculate the overall result of the audit and provide an interpretation of the results specific to the elements and claims management principles. Where a non-compliance has been identified, the auditor must provide comment on how a case record action does not meet the specific criteria and include any relevant supporting information. This should be recorded by inserting a comment in the cell of the Audit results spreadsheet where the non-compliance has been identified. The overall audit result will be expressed as a percentage of the number of compliances relative to the number of applicable criteria. Results will also be expressed as a percentage of compliance against the claims management principles and audit elements. 6 WORKCOVER NSW
Audit planning WorkCover audits Where WorkCover initiates an audit, the following timeline will be followed: More than six weeks prior to audit Four weeks prior to audit Two weeks prior to audit First day of audit During the audit Last day of audit Two weeks from last day of audit Six weeks from last day of audit WorkCover will make initial contact with the insurer s primary contact in writing to: confirm authority to conduct the audit provide information on the proposed date, scope, time and duration of the audit confirm the audit period request relevant documents required and the timeframe for submission request the contact details of the insurer-designated audit team member. The insurer must submit documents and information as requested by WorkCover in the initial contact. WorkCover will not request documents that are already in its possession. In preparation for the audit, the audit team may review documents including, but not limited to: injury management program return to work program (where applicable) quality assurance procedures (optional) risk management procedures (optional) claims estimation manual (if using in house model) claims guide claims data organisational chart. WorkCover will provide the insurer with an audit plan confirming: the scope, dates and location of audit anticipated schedule for the audit activities (eg start and finish times, opening and closing meetings) resource requirements audit team members including the insurer-designated audit team member the specific case records required for the audit. The audit team will hold an opening meeting with the insurer representatives. The opening meeting will include: introductions housekeeping an outline of the audit process the role of the audit team members an explanation of the structure of case records and information management system. The insurer-appointed representative will assist the audit team with identifying further information for consideration, should any non-compliances be identified. Where the lead auditor and insurer agree that a further debrief should be held with the insurer representatives at the end of each day, this should occur. The audit team will hold a closing meeting with the insurer representatives. The closing meeting will include a discussion on the preliminary audit findings. WorkCover will issue the insurer with the audit report. This report will include any requirements as a result of the audit. Insurer will prepare and submit to WorkCover an improvement plan where required (as outlined below). INSURER AUDIT MANUAL 7
Insurer self-audits a. Strategic audit plan It is expected that insurers will have a strategic audit plan in place to ensure that all audits are conducted within the timeframes and other requirements as outlined in this manual. b. Audit plan Adequate planning must be undertaken for each audit by the insurer and the audit team. The above WorkCover planning template can be used for self-audits. Audit outcome Audit report The WorkCover audit report will contain, at the minimum, the following: Section A Report summary and conclusion executive summary a statement that the audit has been performed in accordance with the manual any matters encountered during the audit, including any restrictions on scope or access to information that may have had an impact on the delivery of the audit findings or delivery of the audit objectives conclusion of the overall audit result including identifying case management strengths and initiatives, and areas for improvement detail of any actions to be taken by the insurer as a result of the audit sign off from the lead auditor. Section B Audit results spreadsheet The audit results spreadsheet, including a description of each non-compliance identified during the audit. Audit results and actions The following table outlines the action to be taken based on the initial audit result. Level Audit result Action from WorkCover audit Action from self audit 1 80% 100% No action required, unless specifically directed by WorkCover in the audit report. The insurer may wish to initiate actions to improve performance in areas of non-compliance. 2 60% 79% The audit report may require the insurer to: compile an improvement plan and submit to WorkCover execute the improvement plan, compile a progress report where required and submit to WorkCover within the designated timeframe. WorkCover may: view the improvement plan and progress reports as sufficient to address any areas of non-compliance and issue a final audit score audit the implementation of the improvement plan within a designated timeframe and issue a final audit score. No action required, however the insurer may wish to initiate actions to improve performance in areas of non-compliance. Insurer to complete and implement an improvement plan. Submit a copy of the improvement plan to WorkCover, if requested to do so. 8 WORKCOVER NSW
Level Audit result Action from WorkCover audit Action from self audit 3 Below 59% The audit report may require the insurer to: compile an improvement plan and submit to WorkCover execute the improvement plan, compile a progress report where required and submit to WorkCover within the designated timeframe. WorkCover may: audit the implementation of the improvement plan within a designated timeframe. In the instance that this occurs, a reviewed final audit score will be provided. Insurer to complete and implement an improvement plan. Submit a copy of the improvement plan to WorkCover. A final audit result below 80 per cent may have an impact on licensing terms or the deed. For further clarification on the potential impact, please refer to your WorkCover NSW Commercial or Portfolio Manager. Improvement plan Upon completion of the WorkCover audit, the insurer must, where instructed, compile an improvement plan in the format specified in Appendix B and submit the plan to WorkCover. The improvement plan must: specify the principal person responsible for ensuring the implementation of the improvement plan and monitoring progress outline the actions to be taken by the self-insurer to address all non-compliances identified and improve the current process. specify the persons or roles responsible for performing individual action items outline realistic timeframes based on risk, for the implementation of action items be submitted to WorkCover within six weeks of the last day of a WorkCover audit be implemented within three months of the date of submission to WorkCover, unless where otherwise agreed with WorkCover. WorkCover may: review the improvement plan and request any supporting information to form an assessment of its implementation monitor the implementation of the improvement plan by requesting progress reports audit the implementation of the improvement plan within the timeframes outlined in the audit report undertake a further audit. WorkCover may issue a final audit result on the basis of its assessment of the implementation of the improvement plan. INSURER AUDIT MANUAL 9
Appendix A Insurer audit tool P # Criteria C NC N/A Comments 1. Injury management and recovery at work assessment 1.1 Contact made with the injured worker, employer and nominated treating doctor (where appropriate) within three working days of being notified of a significant injury. Initial communication to key parties focused on educating parties on: 1.2 the importance of recovery at work 1.3 setting expectations on the activities to be undertaken as part of injury management and recovery at work 1.4 roles and responsibilities. Ongoing assessment conducted including: 1.5 Gathering of relevant information (medical, workplace and claims) through consultation with key parties (must include worker and employer at a minimum). 1.6 Analysis of information to determine risks and barriers associated with recovery at work, typical recovery periods and future liabilities (eg potential for reaching permanent impairment thresholds, employer negligence for WID). 1.7 Determining resources and intervention required to maximise recovery at work and return to health in a cost effective manner. 1.8 Decisions and rationale supporting decisions are clearly documented on the case record. 2. Injury management and recovery at work planning Initial Injury Management Plan developed, where appropriate: 2.1 within required timeframe (as outlined in the injury management program) 2.2 in consultation with relevant parties
P # Criteria C NC N/A Comments 2.3 Injury Management Plan includes: goal actions tailored to worker s workplace, rehabilitation, treatment and claims management person(s) responsible for actions stakeholder rights and obligations (including information on how to change nominated treating doctor) review dates. 2.4 Decisions and rationale supporting decisions are clearly documented on the case record. 3. Injury management and recovery at work implementation 3.1 Relevant and regular communication with the worker and employer throughout the life of the claim. 3.2 Planning activities are actioned according to the specified timeframes to ensure timely mobilisation of the services and resources. 3.3 Reasonable actions are taken to educate and influence the employer to provide suitable work to workers who have capacity. 3.4 The insurer informs the employer that it is an offence to terminate an injured worker s employment within six months of them becoming unfit for employment and because the worker is not fit for employment as a result of the injury. 3.5 Planning activities are reviewed on: due dates, or when new information is received. 3.6 Planning activities review included an evaluation: to determine that the return to work goal remains appropriate of the effectiveness of interventions in moving the case to finalisation. 3.7 Planning activities have been communicated to key parties. 3.8 Decisions and rationale supporting decisions are clearly documented on the case record.
P # Criteria C NC N/A Comments 4. Injury management and recovery at work finalisation 4.1 Worker was suitably advised, providing fair notice prior to the finalisation of their claim by defining the extent and the type of benefit within the legislative limits. 4.2 Prior to finalisation, expectations were set for the worker to self-manage their circumstances (eg home exercises, available support services). 4.3 Durability of suitable employment is confirmed prior to case closure. 4.4 Decisions and rationale supporting decisions are clearly documented on the case record. 5. Service provider management 5.1 In engaging the service provider, clear expectations are communicated that intervention contributes to recovery at work or optimum outcome for the worker and the claim. 5.2 Service requests are assessed and reviewed against the test of reasonably necessary intervention. 5.3 Regular and relevant communication with the service provider throughout the life of the claim and specifically: service request decisions made in a timely manner where there is an event-driven requirement. 5.4 Decisions and rationale supporting decisions are clearly documented on the case record. 6. Liability determination 6.1 Liability determination (provisional and claim) is made within relevant timeframes. 6.2 Provisional liability determination is based on: a consideration of relevant information the requirements for determining provisional liability the correct application of a reasonable excuse (where applicable). 6.3 Claim liability determination is based on: a consideration of relevant information the requirements for determining claim liability. 6.4 Where an adverse liability decision has been made, the decision was reviewed by someone other than the original decision maker.
P # Criteria C NC N/A Comments 6.5 Written communications to the worker regarding liability decisions are done in accordance with the WorkCover guidelines for claiming compensation benefits (catalogue no. WC03894). 6.6 Decisions and rationale supporting decisions are clearly documented on the case record. 7. Managing payments 7.1 Weekly payments of compensation commenced, where appropriate, within: seven days of notification for provisional liability 21 days of receipt of a claim worker s usual pay schedule. 7.2 Worker is paid correct amount of weekly payments in accordance with legislative requirements. 7.3 Weekly payments are paid in accordance with the correct entitlement period. 7.4 Worker reimbursements have been made, within 10 business days of receipt of necessary documentation, in support of the amount paid. 7.5 Payments of non-weekly benefits have been paid in accordance with gazetted fees or applicable approvals. 8. Wage reimbursement 8.1 Wage reimbursements to employers are made within: 15 business days of receiving necessary documentation where a wage reimbursement agreement exists five business days of receiving necessary documentation where no wage reimbursement agreement exists. 8.2 Correct amount of weekly payments is reimbursed to the employer, with supporting documentation to verify reimbursement amount on the case record. 9. Claims estimates 9.1 Claims estimate has been reviewed at scheduled and event driven review points. 9.2 Claims estimate is accurate in accordance with WorkCover s Claims estimation manual (catalogue no. WC02838) or a documented self-insurer in-house policy. 9.3 Claim estimates are effectively communicated to the employer in a timely manner to encourage the employer to actively participate in providing suitable work and support a worker s recovery at work.
P # Criteria C NC N/A Comments 10. Work capacity 10.1 Work capacity assessment(s) are conducted at required points in accordance with the WorkCover work capacity guidelines (catalogue no. WC03874). 10.2 Work capacity decisions to cease or reduce weekly payments are communicated to the worker in accordance with fair notice provisions and is attempted to be made by telephone or in person with the worker at the time of the decision. 10.3 The correct date of effect for the cessation or reduction of weekly payments as a result of a work capacity decision is communicated to the worker. 10.4 Where the worker has applied for an internal review, it is conducted in accordance with the WorkCover work capacity guidelines (catalogue no. WC03874). 10.5 Decisions and rationale supporting decisions are clearly documented on the case record. 11. Permanent impairment 11.1 The optimal timing and coordination of the assessment of permanent impairment occurs when there is evidence that the worker has reached maximum medical improvement. 11.2 Where a permanent impairment assessment has been received, the assessment has been reviewed to ensure the correct application of the WorkCover guidelines for the evaluation of permanent impairment (catalogue no. WC00970). 11.3 Where it has been considered that the assessment is not in accordance with the WorkCover guidelines for the evaluation of permanent impairment (catalogue no. WC00970): the worker or their representative is advised within two weeks of receipt of claim in line with the WorkCover guidelines for claiming compensation benefits (catalogue no. WC03894) further clarification is sought from the assessor. 11.4 Where clarification from the assessor is not forthcoming within 10 working days, the insurer arranged an Independent Medical Examination or applied to the Workers Compensation Commission for an assessment. 11.5 Where a claim for lump sum compensation has been accepted, the insurer makes an offer in line with the requirements outlined in the WorkCover guidelines for claiming compensation benefits (catalogue no. WC03894). 11.6 The complying agreement includes the required documents as outlined in the WorkCover guidelines for claiming compensation benefits (catalogue no. WC03894).
P # Criteria C NC N/A Comments 11.7 The claim for lump sum compensation has been determined within the latter of the following timeframes: one month of the permanent impairment being fully ascertainable, or two months after all relevant particulars have been supplied. 11.8 Injured worker has been paid their correct entitlement in accordance with WorkCover s Workers compensation benefits guide (catalogue no. WC03444). 11.9 Where the degree of permanent impairment does not meet the thresholds or the insurer disputes liability in respect of a claim for permanent impairment, a section 74 notice was issued in line with legislative requirements. 12. Work injury damages (WID) 12.1 The claim for work injury damages has been reviewed to ensure it meets the criteria to claim: the injury resulted in the death of the worker or a degree of permanent impairment of the worker that is at least 15 per cent the injury was caused by the negligence or other tort of the worker s employer. 12.2 Where WID proceedings commenced three years outside of the date of injury, the worker had leave of the court in which the proceedings were to be taken or alternatively, an explanation for the delay was provided. 12.3 A review of the claim was performed to identify any potential recoveries or liable third parties. 12.4 The claim was determined no later than two months after receipt of all particulars, and action taken by either: the issue of a section 74 notice, or an offer of settlement. 12.5 Response to the pre-filing statement was made within either 28 or 42 days. 12.6 A formal response to an Application for Mediation within 21 days is made and indicates whether the respondent(s) will participate or decline to participate in the mediation and a record of the outcome of mediation is on the case record.
P # Criteria C NC N/A Comments 12.7 Settlement documents clearly identify the terms of the settlement including: 13. Commutations the amount if inclusive of worker s legal costs whether clear of all previous weekly payments subject to any Medicare or Centrelink clearances date weekly benefits will cease any requirements around previously incurred section 60 expenses. 13.1 A legal practitioner has certified in writing that the worker has been advised of the: full legal implications of the agreement the desirability of the worker obtaining independent financial advice worker has confirmed in writing that the worker has been given and understands the advice. 13.2 The commutation has been lodged with the Workers Compensation Commission. 13.3 The agreed commutation amount has been paid within seven days after the agreement is registered or within such longer period as the agreement may provide. 14. Information and records management Where a case handover has occurred: 14.1 a review of the whole claim and the specific case strategy occurs at the time of the case handover 14.2 the case manager receiving the case has made timely contact with the employer, worker and affected parties to establish working relationships. 14.3 Work status code matches the work status of the worker. 14.4 There is a demonstrated application of confidentiality and privacy principles to the collection and maintenance of information within the case record.
Appendix B Improvement plan template Criteria # Criteria Action Responsibility Timeframe Activities completed (to be completed as progress made) Date complete
Catalogue No. WC01591 WorkCover Publications Hotline 1300 799 003 WorkCover NSW, 92 100 Donnison Street, Gosford, NSW 2250 Locked Bag 2906, Lisarow, NSW 2252 Customer Service Centre 13 10 50 Website workcover.nsw.gov.au ISBN 978 1 74341 592 4 Copyright WorkCover NSW 1014