San Francisco, CA – Labor Code §§129 and 129.5 require the Audit and Enforcement Unit of the Division of Workers’ Compensation (DWC) to conduct a profile audit review (PAR) for all adjusting locations of California workers’ compensation claims at least once every five years.
Performance of the adjusting locations is measured in five areas of claims administration:
- The payment of accrued and undisputed indemnity
- The late first payment of temporary disability / first notice of salary continuation
- The late first payment of permanent disability and death benefits
- The late subsequent indemnity payments
- The provision of notices with QME/AME advice.
The administrative director annually establishes profile audit review and full compliance audit (FCA) standards in accordance with Labor Code §§129(b)(1) and (2) and Title 8, California Code of Regulations §10107.1. The 2016 standards are based on the audit results of calendar years 2012 through 2014.
Performance standards for 2016
The PAR performance standard for audits conducted in 2016 is 1.51082. Audit subjects with PAR performance ratings of 1.51082 or lower will be required to pay any unpaid compensation, but no penalties will be assessed. If an audit subject’s PAR performance rating is 1.51083 or higher, the audit will expand to a FCA, and an additional sample of indemnity claims will be audited.
The FCA performance standard for audits conducted in 2016 is 1.67880. Audit subjects with an FCA performance rating of 1.67880 or less will be required to pay any unpaid compensation and penalties will be assessed for all violations involving unpaid and late paid compensation. If an audit subject’s full compliance audit performance rating is 1.67881 or higher, an additional sample of denied claims as well as the expanded sample of indemnity claims will be audited. Penalties will be assessed for all violations as appropriate pursuant to 8CCR §§10111 through 10111.2.
More information on the performance standards that will be in use for the profile audit reviews and full compliance audits during calendar year 2016 will be posted on the DWC Audit and Enforcement Unit web page.
Source: CA DWC