Purpose

The objectives of our examination were to determine whether claims were appropriate and complied with (i) the New York State Workers’ Compensation Law and (ii) mandated fee schedules (where applicable).

Background

The Board processed nearly 431,000 claims totaling nearly $829 million from its four special funds in 2018 - the Uninsured Employers Fund, the Special Fund for Disability Benefits, the Second Injury Fund, and the Fund for Reopened Cases. From January through March 2018, the Board processed claims for all special funds using the Board’s FMIS. Claims were reviewed and approved by staff at the: (i) Board, (ii) Special Funds Conservation Committee (SFCC), or (iii) TPAs. In April 2018, the Board fully transitioned its claims payment process to the SFS.

Key Findings

Our office identified 7,500 errors totaling more than $6.3 million. Of these, 775 errors totaling more than $4.4 million were identified as a part of our daily audit. In addition to our daily audit, we identified 6,725 processing errors totaling nearly $1.9 million that occurred when the Board uploaded claims into the SFS. We also determined that incorrect payment information provided by the Board for both FMIS and SFS payments resulted in the issuance of 2,235 erroneous 1099-MISCs, totaling over $1.3 billion, which our Office corrected and reissued.

Key Recommendations

• Take necessary steps to ensure the Board and the TPAs accurately process claims.
• Recover any monies paid inappropriately as a result of incorrect uploading of claims to the SFS.
• Ensure vouchers correctly indicate whether or not the payment is reportable to the IRS.
• Continue to recover duplicate claims identified in the 2017 annual report to the Board.
• Continue to work with this Office to identify areas of improvement to streamline claims processing.