Workers'
Compensation System
A new workers' compensation case may be established in ClaimLink in any of three ways, all of which are similar in nature:
1. Electronic Accident Reporting. This optional module permits new accident information to be entered by non-technical personnel, such as supervisors and managers of the injured worker. All information about the injury or illness may be entered in this module. However, some additional information must be added by risk management personnel before the case can be actually established. This additional information includes such things as assignment of the examiner, entering reserves, and determining if the case is a first-aid case or a claim.
2. First Aid Case. A first aid case may be entered directly by any authorized risk management personnel. A first aid case carries all of the same information as a regular claim, so it can be analyzed in the same fashion, and/or can be converted to a regular claim if it is determined that the loss is outside first aid guidelines. First aid cases are reported separately from regular claims, and are not reported to state authorities.
3. Claims. A claim may be entered directly by any authorized risk management personnel. If desired, the system will automatically assign a claim number to the case being entered. A claim is identified as a medical only case or an indemnity case automatically by the system based on the presence or absence of indemnity reserves.
Claimant information is retained separately from case information in ClaimLink, and is recorded under the claimant’s social security number. Thus, a change to any claimant data while entering data for a particular case will change the central file and will be reflected for all cases for the same individual. If desired, access to claimant changes can be restricted to specific users only. Thus reducing the chance that any unauthorized user might make a change of name or address in order to redirect payments fraudulently to another person.
ClaimLink is capable of issuing either checks or vouchers, as desired by the organization. In addition to requests for payments, hand-typed payment transactions may be recorded in the system. Ancillary payment-related transactions accommodated by the system include voiding of payments, payment corrections, payment transfers, reimbursements, recoveries and adjustments.
ClaimLink contains an easy-to-use, yet flexible, Diary system that keeps track of tasks scheduled for the future, as well as tasks that have been accomplished in the past. The system permits a variety of users to create diary entries for their own use, as well as for others who may need to perform tasks for the claim (supervisors and claims assistants, for instance). Diary entries can be viewed on a summary screen or on a detail screen, and completed tasks can be viewed on a diary history screen. Entries may be accessed in a number of ways, depending on the cross-section of diaries to be viewed. For instance, diary entries can be viewed for a particular user/examiner, for a particular period of time, for a particular diary reason, for a single case, or for any combination of the above.
The Action Plan portion of the system is designed to encourage the examiner to record key information about each case, with a summary of the course of action to be pursued. It contains lost time information, physician information, compensability considerations, subrogation information, remaining tasks to be completed, as well as a general comments section.
ClaimLink provides information and reports required by various governmental agencies, and to assist the organization in properly adhering to all applicable regulations. There are a variety of reports and forms that are produced by the system to meet these needs as follows:
Employer’s First Report of Injury. This form, required for each new injury may be automatically produced by the system. The system contains all information required for this report, which will be produced as soon as a valid claim is entered in the system. The system does not produce this form for first aid cases.
Benefit Notices. These notices, required at various points for disability reasons, are produced by the system for state of California organizations. When the first payment of temporary or permanent disability payments is entered, the system will automatically issue the appropriate Benefit Notice if possible, or will prompt the user for data if additional information is required. When the final payment for either temporary or permanent disability is requested, the user may simply enter the few items of information required for the appropriate Benefit Notice, and the system will then produce that notice. Other Benefit Notices may also be requested and printed by the system, including Delay Notices, Denial Notices, Rate Change Notices, as well as most other notices. The system records information about each Benefit Notice which later can be viewed on the Document History screen.
Case Log. The system is able to produce the Case Log, which lists each new claim, in the order in which it was received. This tabular report shows all information required by the state of California, and can be produced on a regular basis, or upon demand.
OSHA Log of Occupational Injuries. This log, which lists all of the injuries and/or illnesses reported during the year may be produced by the system either on a regular basis, or upon demand. In addition to the detail information about each injury, it provides recap totals by location.
1099’s. The system gathers provider and payment information at the end of each calendar year, and produces the 1099 forms required both by the federal government and state governments. Reportability may be specified on the Provider master file, and this in conjunction with the aggregate amount of payments issued during the year will determine if the form is to be produced.
Annual Reports. ClaimLink automatically produces the "Face Sheet" for the state of California Annual Report, as well as the supporting detail report. This can be produced either on a calendar year basis or a fiscal year basis (for public entities), as required by statute.
Letter, Document and Benefit Notice Generation. The system contains an integrated letter/document generation module that permits examiners (as well as supervisors and assistants) to request a wide variety of letters that will be produced by ClaimLink utilizing any laser printer. These letters contain a combination of standard verbiage, data obtained from the system, and information added by the user at the time the letter is requested. Requested documents can be printed with ease whenever desired. With this ClaimLink feature, a word processing package will only be necessary for special one-time only letters.
Reporting to the Reinsurer. Reinsurance agreements are codified in the Reinsurance Profile function, and based on this information, any qualifying case will be automatically reported to the reinsurer. Standard reporting reasons include reaching a percentage of the self-insured retention, death cases, multiple injury cases, and reaching a prescribed number of disability days. Additionally, ten custom tailored reporting reasons can be identified.
ClaimLink produces several reports which are designed to assist the examiner, supervisor, and claims manager in controlling overall work load, and in assisting in the administration of each case. Most of the reports described below can be processed at any desired frequency, and may be produced by examiner, or at any of seven organizational levels.
The first of these reports is the Examiner Diary. Although each examiner may work the diary entirely from interactive screens, some individuals prefer to utilize a hard copy report upon which they can make notations as they proceed. Typically, the hard copy diary report, which is produced by examiner, and by day, is prepared at the end of each week, and includes all diaried actions in the past for which action has not yet been taken, as well as the next two to four weeks of scheduled future activity. Upon occasion it may be desirable to just list the diaried entries for a particular reason, such as trials, which can then be used as a trial calendar.
The Case Profile report may be requested by any authorized user as needed, and produces a detailed report for a selected case. This report includes all of the basic information about the case, and may optionally also include all (or part) of the payments for the case, all (or part) of the case notes recorded for the file, and the diary information on file for the case. This can be useful when having meetings or hearings about a case in that it contains current information about the case all in a short, concise report.
The Caseload report summarizes a number of statistics for each examiner, unit, and adjusting office. It contains information such as the number of new claims established for the examiner in the last month, the number of reopened cases in the same period, and the number of cases closed in the same period. It breaks out the number of cases for these categories into subcategories for active cases, settled cases, companion cases, litigated cases, and total cases; and shows the total amount of payments and incurred cost for each category. Additionally, the report shows the total open caseload at the end of the reporting period by indemnity, medical-only (and total) cases, for the subcategories enumerated above as well as showing the total amount of payments and incurred cost for each of these categories. This report permits a quick determination of the distribution of the caseload, the closing ratio for each examiner, and other tools of measurement. For each unit, and for each office, the system computes per-examiner averages for all of the categories, and subcategories above.
The system produces a Medical Only Aging report, which categorizes open medical only cases by length of time the case has been open. By reviewing the cases in the categories open the longest, the medical only examiner may concentrate effort on those cases that have dragged on the longest. At the end of the report for each examiner, the system presents a recap of the cases falling into each category (1-30 days, 31-60 days, 61-90 days, 91-180 days, 181-360 days and over 360 days), and the percentage of the total caseload that falls into each category. It should be noted that there is a similar report for indemnity cases, utilizing longer periods of time for categorization.
ClaimLink contains a number of reports which are designed to provide management with information to analyze the financial performance of the workers’ compensation program, to control costs for the program, and to provide other information that will help to keep the program running properly. Like most other reports, these reports can be produced at all organizational levels, and may be produced at any desired frequency. A few of these reports are described below.
The Claim Summary by Injury Date report includes totals for all cases, whether open or closed (but not including archived cases), and presents this information by injury year. It has two basic sections, with the first showing the number of cases, and the second showing financial figures. The number of cases are listed on three lines, one for open cases, one for closed cases, and the last for all cases. Each of these lines is broken down into a category for indemnity cases, litigated cases, medical only cases and total cases. On the financial section of the report, the amounts are listed on four lines: one for compensation, one for medical, one for expense, and the last for all amounts combined. Each of these lines is broken down into a category for payments to date, future reserves and total incurred cost. A variation of this report breaks down the financial information (for payments to date) into each of the thirteen standard payment categories instead of just compensation, medical and expense.
The Analysis of Workers’ Comp Litigation Expenses report is designed to present information about each legal firm, and the caseload which has been referred to it. All cases assigned to each firm are listed if they have had payments to the firm during the past year. The report identifies the firm by name, identifies each case by number and claimant name, shows total incurred cost for each case, and breaks down fees paid to the attorney both for the current period as well as from inception to date. For information, a column is presented showing the percentage that the attorney fees bear to the total incurred cost for the case. Additionally, any other legal expenses paid for each case are listed (and to whom those payments were made), and a column is presented showing the percentage that all legal costs for the case bear to the total incurred cost. A total line for each firm aggregates the figures just described to give an overall view of the actual and relative costs for legal expenses.
In order to assist management in determining the promptness of information being reported and recorded for each case, ClaimLink prepares a New Claims Lag Analysis report which presents the lag time between the date of injury, the date of knowledge, the date the administrator received information about the case, and the date the case was entered in the system. By showing the time gaps between these dates on a case-by-case basis, and by presenting totals at various organization levels, problems in prompt reporting and/or processing can be identified so corrective measures can be instituted. The system shows both the median and the average lag time for each of the three potential lag periods, and reduces excessive gaps (over 90 days) so that the averages are not distorted by a few exceptional cases.
The loss prevention reporting generated by ClaimLink is perhaps one of the most important features of the system. Clearly, an injury that is prevented saves a lot more money that an actual injury that it administered even in the most cost effective manner. The reports available attempt to highlight problem areas, identify situations with worsening experience, and help spot other opportunities for prevention.
The Loss Control Management Summary report has eleven different breakdowns that will help identify problem areas, and like other reports can be processed at any desired organizational level. These reports show both the frequency of accidents, and the severity (incurred cost) of the same accidents by a variety of categories, and depict this information also in bar graph form so that unusually bad experience can be readily spotted. The list below identifies the eleven separate reports that are currently available under the format of this report:
Site of Loss
Period (Month) of Year
Day of Week
Age of Claimant
Time of Day
Type of Loss
Part of Body
Nature of Loss
Agent of Loss
Cause of Loss
Months of Service
Department
Many of the reports prepared by ClaimLink are utilized in one way or another for accounting and record keeping purposes. However, there are some special reports that are worthy of mention, and which are described below.
A basic report that is necessary for accounting purposes is the Check Register. This report shows all of the payments issued, including vouchers, along with any of those payments that have been voided. These disbursements are broken down into two sections, the first for computer generated checks and the second for hand-typed checks. In another section of this report, other disbursement related transactions are shown, and include payment corrections, journal adjustments and payment transfers, all of which reflect a debit/credit correction of some original mis-coding. In the last section of the report, receipts are shown, and include both reimbursements and recoveries. At the end of the report, a recap page is presented, breaking the payments into summary totals by type of payment (temporary disability, medical, legal etc.), by type of transaction (computer generated check, hand-typed check, recoveries etc.), and by type of claim (indemnity or medical only). A separate section of the register is prepared for first aid payments, should those be utilized. The system may also producea Penalties Register, which reflects only penalty payments made under the laws of California.
Loss Development reporting encompasses two reports, which may be used for actuarial purposes. The first of these is a Financial Loss Development report which provides information about the cases for each injury year, breaking out the balances for payments, future liability and total incurred cost at the end of each subsequent year. These costs are identified separately for direct costs (indemnity and medical), and allocated costs, which reflect legal and other expenses. Percentage figures for each year show the relative growth of costs as time progresses. This report may be processed at any reporting level.
The second of these two reports is called the Loss Development Trends report, and is designed to show case counts by a variety of categories, as well as average costs, all developed in the same manner as the Financial Loss Development report described above. Therefore, for each injury year, the cases are trended through each subsequent year, showing the counts and averages at the close of each of those years. Figures presented are broken down into major sections for medical only, indemnity, litigated, and all cases. Under each of these sections there are counts for the total number of cases, the number of open cases at year end, the number of closed cases at year end, the average cost of all closed cases at year end, and the average number of days that cases were open. This report may also be presented at any organizational level.
For additional information on the ClaimLink workers' compensation system, contact John Johnson at (626) 440-1676 or e-mail to j_johnson@ sucaba.com
All Material Copyright © 1996, 1997, 1998, 1999, 2000 Sucaba Company, Inc.