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The Exciting World of FROI & SROI
David L. Snyder, Esq.
Melanie M. Wojcik, Esq.
Rebecca M. Guerra, Esq.eClaims: Today’s Agenda I.Background II.New Claims ¡Accepting Claims ¡Denying Claims III.Ongoing Claim Management ¡SROIs ¡Legacy Claims ¡Acquired Claims IV.Conclusion ¡Summary of Changes ¡Practice Points
Presented by David L. Snyder, Esq.Background Spring of 2012: Board announces transition to electronic reporting system called “eClaims”Objective: Provide timely, accurate, and credible electronic reporting which will reduce employer costs and make it easier for injured workers to receive timely benefits Adoption of IAIABC Electronic Data Interchange (EDI) standards What is eClaims? Electronic system for managing claims and reporting case events Keep paper filing for C-240, C-11, PH-16.2, reimbursement requests, attached documents and correspondence Alphabet Soup Rolling Out eClaims Implementation deadlines 3/10/14: Implementation complete Training courses & materials New regulations N.Y. Comp. Codes R. & Regs. Tit. 12 § 300.22 (effective 4/23/14) Changes to existing regulations N.Y. Comp. Codes R. & Regs. Tit. 12 § § 300.23, 300.38 (effective 4/23/14) eCase Largely unchanged “Summary of benefits” tab captures all SROI submissions historically “Cumulative benefits” tab captures all benefits paid – medical and indemnity If two carriers involved, able to switch viewing screens to view different carriers’ FROI/SROI information Print FROI/SROIs directly from eCase eClaims Inquiry NEW! web application which provides the ability for Trading Partners (Senders), Vendors, Insurers and Third Party Administrators to view both accepted and rejected claim transactions submitted to the BoardShows all transactions and status (accepted or rejected) and reason for rejections Use anticipated by “Flat filer” vendors: e.g. Mitchell: ¢“Eliminate manual data entry by exporting FROI/SROI data from your claims management system via SFTP (secure file transfer program).”
Presented by Melanie M. Wojcik, Esq.New Claims 1.The FROI 2.Accepted claims 3.Denied claims 4.Accepting a claim without prejudice under 21-a 5.Partial denials – when medical liability may be accepted, but you are disputing indemnity 6.Practice Points ● ● ● The FROI FROI – First Report of Injury The FROI will replace the C-669 and the C-7 A FROI will always be the first form filed Accepting a Claim: Medical Only Claims FROI-00: for medical only claims where claimant will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid as defined by Section 110 (2), and there is no lost time beyond the working day or shift on which the accident occurred as defined by Section 110(2) and proposed amendment to NYCRR Section 300.22. Notification to be made within 18 days after the disability event or within ten days after the employer has knowledge of the disability event, whichever period is greater. Notification required for claims with more than two treatments. Accepting a Claim: Medical Only Claims (cont’d) This is the same rule that previously applied to the C-2. Difficult to ascertain within the deadlines. If lost time, then the FROI-00/SROI-IP should be filed if carrier is paying lost time or FROI-00/SROI-EP if the employer is paying wages. Notification codes on FROI-00: “N” (notification only), “M” (medical), and “I” (indemnity) If in the future, claimant begins losing time, a SROI will be filed. Controverted Claims Before EDI, a C-7 would be filed, either by your office or by your counsel. Your legal counsel would be required to certify the C-7. New procedure: if claim is to be denied you will file either a FROI-00 then a SROI-04, or a FROI-04. Legal counsel cannot file these forms on your behalf. Deadlines for timely filing remain the same. FROI-04 to be filed within 18 days after the disability event or within ten days after the employer has knowledge of the disability event, whichever period is greater. If not filed in accordance with these timeframes, may be subject to $300.00 penalty in accordance with Section 25-2(a). Controverted Claims – Important! Counsel cannot “file” the form; however, counsel should still be involved to identify viable controversies. Need to immediately secure claimant and witness statements, HIPAA authorizations, OC-110a forms for investigation of prior treatment and pre-existing injuries. Counsel should continue to assist in identifying issues to be raised. We have new forms, but are still subject to Rocket Docket rules. Controverted Claims: Example One Emmett the construction worker is injured on 12/10/13. He reports his injury on 1/15/14. You want to controvert based on untimely notice. FROI-04 must be filed by 1/25/14 (ten days after the employer had knowledge of the disability event). Controverted Claims: Example Two Joe Fibsalot alleges a right knee injury occurred on 12/5/13. He tells his supervisor on 12/9/13, a Monday. A co-worker tells the supervisor that Joe hurt his knee skiing over the weekend. Joe is taken out of work by Dr. Believesanything on 12/12/13. When should your notice of controversy be filed? As the employer wants to controvert from the outset, you can file the FROI-04, and it must be filed by 12/23/13 – 18 days after the disability event. Note that ten days from the date the employer had knowledge was 12/19/13. Controverted Claims: Filing Deadlines FROI to be filed within 18 or 10 deadline. SROI-04 within 25 days from indexing or within 18/10 whichever is greater. For example, case is being controverted for date of accident 1/2/14. You file FROI-00 on 1/12/14, but claimant does not file a C-3 or any medical indicating a work related injury. The claimant files a medical report and C-3 on 1/31/14. The WCB indexes claim on 2/5/14. SROI-04 filed on 2/20/14 (within 25 days from indexing). Controverting a Claim: continued If a paper C-7 was filed before you went live with EDI, then a FROI-UR would be the appropriate first filing. In other words, if the claims administrator has not previously filed a paper C-7 or any other FROI, then the Board would expect a FROI-04 when controverting the claim. If you have already filed a FROI, then a SROI-04 would be expected to controvert the claim. Controverting a Claim: Denial Codes Select the Right Denial Codes: Example Mr. Driver alleges a low back injury occurred while he was delivering packages on Christmas Eve, 12/24/13. He reports the injury to his employer on 1/10/14. Employer reports that the claimant was actually done with his shift and slipped in a parking lot while doing last minute Christmas shopping, as reported by his ex-wife who works for the same company. Carrier promptly filed a FROI-04 on 1/18/14 (within ten days of when the employer was notified of the “disability event”) and raises “2E – no injury per statutory definition” but nothing else. Select the Right Denial Codes, cont’d. The pre-hearing conference is scheduled for 2/16/14 and carrier sends the notice to its counsel on 2/1/14. Counsel realizes that additional issues should have been raised including 1D (does not meet statutory definition of accident), 2D (no medical evidence of injury), 1E (deviation from employment) and 1I (presumption does not apply). Counsel quickly files a SROI-02 and PH-16.2 raising the additional issues, but advises that the Judge may preclude carrier from pursuing the “accident” defenses as they were not timely raised. Select the Right Denial Codes, cont’d. Denials will have to be certified by legal counsel at the pre-hearing conference. If FROI-04 or SROI-04 filed, and additional issues need to be raised, then a SROI-02(change), can be filed to amend your notice of controversy. However, deadlines for issues to be raised, (accident or employer/employee) relationship must still be considered. Some codes can be used to mean more than one thing. There are no specific occupational disease codes, so if you are raising no OD, clarify in the denial narrative. Denial Reason Narrative Denial reasons may be clarified using DN0197 (denial reason narrative). This will be important to use, to clarify the issues being raised, as many of the denial codes have multiple meanings. For example, denial code 3E means “no insurance policy in effect on date of accident,” which can be used to raise an issue of proper carrier, or cancellation of coverage. Accepting a Claim Without Prejudice Carriers may still accept claims without prejudice under 21-a, and are required to file a SROI, presumably a SROI-IP (initial payment) immediately upon beginning temporary payment of compensation or for treatment. On the SROI form, there is an area indicating “agreement to compensate” with options of “with liability” or “without liability.” If accepting under 21-a, use “Agreement to Compensate Code” (DN0075) with value of “W” (without liability). You will then have a year from the date of filing in which to controvert the claim, although you will have to continue payments of medical and indemnity while performing further investigation. If you controvert at some point within year: file a SROI-04. Partial Denials Denying indemnity in whole, but paying for medical. Use FROI-00 and SROI-PD. Example would be a case where there is no medical evidence to support lost time, or a claim where the injury is not disputed but any claim for lost time is: for example, claimant is injured, and refused light duty offer from employer. Denying indemnity in part, not medical. Use FROI-00 and SROI-PD. This would be a situation where there was medical evidence to support lost time for a short period, but then no further evidence and claimant remains out of work. New Claims: Practice Points Coordinate with employers to determine whether or not a claim should be controverted: ¡C2, Witnesses contacted for statements, HIPAA releases Involve counsel before filing FROI-04 or SROI-04 to review appropriate issues/investigation: ¡If counsel assists you with the denial, then the file can be monitored so that the PH16.2 is timely filed. Practice Points, cont’d. Paper copies of FROI and SROI denials must be served on the claimant, claimant’s counsel and other parties: email/fax if accepted by claimant’s counsel and claimant Paper PH-16.2 statements are still required to be filed 10 days prior to pre-hearing conference. If you file the denial on the 25th day: ensure confirmation that it was received: direct filers will receive immediate notice; flat filers need to check for successful transmission. Practice Points, cont’d. If you use a flat filer, file a few days before the deadline to verify that it was accepted by the Board. If a file is rejected, it will because of technical defect not substantive reason. IMPORTANT: FROI must always be filed on or before the 18th day after the disability event or within ten days from the date that the employer has knowledge of the disability event. This applies to all claims!
ONGOING CLAIM MANAGEMENT
Presented by Rebecca M. Guerra, Esq.Ongoing Claim Management 1.SROIs 2.Reporting benefit changes 3.Legacy claims 4.Sub-annual reports 5.Acquired claims 6.Practice points SROI Subsequent Report of Injury Replaces C-8/C-8.6 (reports change in indemnity/wages because of some event) MTC determines purpose of report: Board has provided “MTC Filing Instructions” SROI-04/SROI-PD used in denials; remainder of SROIs used on accepted/established claims On ongoing claims, generally required to be filed within 16 days after event occurred which led to change in benefits; on new claims where initial payment, file within 18/10. SROIs, cont’d. Report all penalties, medical expenses, M+Ts, atty fees, interest; do not need to report defense fees presently Do not need to file a SROI every time you make a payment! Benefits broken down by type (total/partial) Uses “through” dates, not “to” dates Document overpayments, apportionment, third party offsets Indemnity Benefit Reporting SROI-CA: Reportchange in rate only ¡e.g. change to AWW SROI-CB: Report change in benefit type and benefit rate ¡e.g. change from TT to TP SROI-PY (payment report) lump sum payments (32), payment of awards, penalties SROI-S_ (suspension) ¡ ¡ Other SROIs Reduced Earnings Resumption of benefits Wages resumed General Data Element Changes: FROI-02/SROI-02 Benefits exhausted: SLU/PPD benefits Legacy Claims Claims which were in Board database prior to eClaims and already have WCB Number (JCN) When reportable event occurs, administrator reviews “extract” file (FROI-UR if present; FROI-00/AU if not) FROI-UR: file with appropriate SROI(s) on legacy claim when some reportable event occurs SROI-UR: summarize historical information regarding the claim; only required if indemnity paid previously Sub-Annual Reports SROI-SA: two per year on open cases (not marked NFA or reopened after being marked NFA) or closed cases (NFA) with continuing indemnity payments Due on open “medical only” claims Each SROI-SA is a cumulative total of each benefit paid to date on the claim Due 180 days from date of accident or where no accident date/partial: from filing of first FROI While the regulations would not seem to impose this requirement on legacy claims, Board’s FAQs say otherwise Mailing to parties optional SROI-SA Deadlines Acquired Claims Required to report in eClaims when a claim has been acquired from another administrator FROI-AQ (can be used if prior claim administrator): within 10 days of acquisition FROI-AU (if no FROI/SROI previously filed): within 30 days after the rejection of FROI-AQ SROI-AP (payments begun): within 16 days Need to report “unallocated prior indemnity benefits”: what prior claims administrator paid in lump sum SROI Practice Points Use the proper MTC. Pay attention to filing deadlines, which may vary by reason for filing. Use the narrative fields for explanations, e.g., SROI-SJ suspension – explain why suspending. Serve on claimant and claimant’s counsel. File attachments directly with the Board.
Presented by David L. Snyder, Esq.Summary of Changes Elimination of C-2 filing Elimination of C7, C-669, and C-8/C-8.6 SROI-SA Sub-annual reports Denial codes FROI/SROI section in eCase Trading partners How Counsel Can Assist With eClaims Determine compensability of claim and legal defenses Assist with denial codes and narrative explanations Prepare PH-16.2 and advise on evidence needed to defend claim Advise on potential penalties and repercussions for filing deficiencies Practice Points Pay careful attention to ensure that the right MTC code is utilized based on the event being reported Use narrative fields to explain when necessary Make sure you receive “Transaction Accepted” acknowledgement of transaction; if rejected, redo C-2F paper form not to be filed, but still should be completed and retained by employer Separately submit any attachments to the Board via email, fax or mail Practice Points, cont’d. If either of the parties of interest (POI) have designated email for service, the carrier can serve the PDF via email for that POI, but if claimant does not à PDF must be served by mail on claimant Mail the printable report, when required, to the claimant and his or her counsel within one business day File reports well prior to 6:00 P.M. to ensure successful transmission (check Board FAQs for update – certain days extended to 8:00 P.M.) Additional Resources Email: email@example.comTelephone: 877-632-4996, Option #7; or call any of the Board’s District Office Numbers and select Option #5 Website: www.wcb.ny.gov à eClaims link Questions and Answers If a FROI-00 has no witness names would the employer be prevented from producing witnesses at a hearing? ¡The FROI-00 is the equivalent of what was included on the paper C-2 today so same rules would apply. However, if it is a controverted claim (FROI-04) it would be different since the PH-16.2 asks for this and all controverted rules will remain the same. How does the FROI-02 differ from the SROI-02? ¡They are only different in what you can change. The FROI and SROI have different data elements in some instances. For example, the Claimant's Address and Phone are FROI data elements only. A FROI-02 can be submitted anytime in the life of the claim, so submission of a SROI does not stop the carrier's opportunity to submit the FROI-02 if they found it necessary. Also, I just wanted to note that the FROI-02's are only "servable" on the parties if you are changing Full Denial reasons. So a carrier who is just changing a claimant's address is not required to mail a copy of the 02 to the parties like they would other certain FROI's and SROI's. Questions and Answers What do you do when a SROI is not “required” but you want to make parties aware of what has been done with payments? For example, a client advised that they were unsure what MTC to file and contacted e-claims, and were told that they did not need to file anything. In this situation, three periods were awarded by the Judge that were previously held in abeyance. The carrier was allowed to credit an overpayment so no money was moving. Optional – file SROI-PY. Questions and Answers The state will provide an extract list of legacy claims that were reported prior to the ‘go live’ date. FROI-URs will be generated on these. We may have some claims in our system that pre-date the go live date that will not be included on the extract list. Our system will automatically generate a FROI-OO, which is a first report. Will these be considered late filings of first reports and will we be subject to penalties on these? ¡No. If a case is not listed in the extract file, the Board specifically directs you to file a FROI-00 or FROI-AU. As that is their explicit direction, you will not be penalized for complying with it. Are legacy claims that are already in payment exempt from the New York agreement to compensate code requirement? ¡Per the Element Requirements table available on the Board’s website, the Data Element of “Agreement to Compensate” is listed as “if applicable” for FROI-UR filings on legacy claims. It is not mandatory.