Purpose

The objective of our examination was to determine whether daily workers’ compensation payment requests by claimants and medical providers (claims) during the period January 1, 2015 through December 31, 2015 and claims paid twice during the period January 1, 2014 through December 31, 2015 were appropriate and complied with the New York State Workers’ Compensation Law and mandated fee schedules.

Background

The Board administered four sole custody funds in 2015.Board staff enter workers’ compensation claims data into the Board’s automated payment system, where the claims are subjected to various system edits and validation checks, approved by the Board and submitted to our Office for approval prior to payment.

Key Findings

Our examination of daily payment requests, identified and disallowed 206 claims totaling $1.85 million. Claims were either incorrectly coded ($916,031) or otherwise inappropriate ($941,509) due to unsupported charges, noncompliance with mandated fee schedules, computation errors, duplicate payments, or other miscellaneous errors.

Our examination of claims paid twice identified 798 potential duplicate payments totaling nearly $2 million. Of the 798 payments, the Board confirmed 417 duplicate claims for $1.62 million, including 66 for which providers and claimants have already refunded $220,000. The Board intends to recover the remaining $1.4 million. The Board also confirmed 61 claims for $107,000 were not duplicate payments and is continuing to review the remaining 320 claims for $232,000.

Key Recommendations

• Continue to reinforce the importance of accurately processing claims to Board staff.
• Continue to review potential duplicate payments and recover any overpayments identified as needing to be recovered.
• Ensure Board staff follow up appropriately when system alerts indicate a potential duplicate payment.