Purpose

The objective of our examination was to determine whether claims were appropriate and complied with the New York State Workers’ Compensation Law and mandated fee schedules.

Background

The Board processed claims totaling over $830 million for four sole custody funds in 2016 – the Uninsured Employers Fund, the Special Fund for Disability Benefits, the Second Injury Fund and the Fund for Reopened Cases. Board staff enter claims data for all special funds claims 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

We identified $1,224,077 of inappropriate claims.

We also identified two high-dollar outlier claims that resulted in $2,633,204 in total savings. For these claims in particular, Board staff members entered incorrect data in fields used to calculate the payment amount resulting in artificially higher amounts to be paid.

Separate and apart from our daily audit, we reviewed claims processed by the Board on a post payment basis to identify potential duplicate payments. For calendar year 2016, we identified 210 potential duplicate payments totaling $344,000.