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In
1992, the Oregon Workers’ Compensation Division (WCD) implemented
the Quarterly Claims Processing Performance (QCPP) Audit. The QCPP
audit is a system-generated summary of reports submitted to WCD
by insurers and self-insured employers and entered in the division’s
claims information system.
In 2010, WCD discontinued issuing penalties based solely on the QCPP audit statistics. WCD continues to provide insurers and self-insured employers with statistical summaries for informational purposes, which allow companies an opportunity to correct applicable claims processing issues. Also, WCD continues to use this self-reported data provided by the insurers and self-insured employers for performance measures of overall industry compliance levels.
The QCPP audit continues to review the insurer and self-insured
employer reports for timely processing performance of four key claims-processing
requirements, which include:
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Claim
reporting: Insurers and self-insured employers must report
initial and aggravation claims to WCD within 14 days of the
acceptance or denial date.
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First
payment: Insurers and self-insured employers must make first
payment of temporary disability (TD) within 14 days of either:
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The employer's date of knowledge of a claim, if an attending physician or an authorized nurse practitioner authorizes TD within the first 14 days.
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The date an attending physician or an authorized nurse practitioner authorizes TD, if more than 14 days from the employer's date of knowledge.
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The
date an insurer or self-insured employer receives authorization
from an attending physician or an authorized nurse practitioner,
when the authorization was requested, but not received within
the first 14 days. OAR
436-060-0020
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Examples
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Claim
Acceptance or Denial: Insurers and self-insured employers
must accept or deny a claim within 60 days of the employer's
date of knowledge of the claim.
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Notice
of Closure: Insurers and self-insured employers must close
a claim within 14 days of the date the claim qualified for
closure.
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WCD
now issues these penalties for performance deficiencies and inaccurate
reporting during the annual audits.
The industry performance standards have not changed. Performance
categories that relate to providing benefits to workers remain at
a 90 percent timeliness standard, and claims reporting to the division
remains at an 80 percent timeliness standard.
Industry averages for initial
claims processing is the total number of claims reports submitted
each quarter for the above three claims-processing areas, and the
totals by year.
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