Workers’ Comp Audit Mistakes: What to Look For

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No company owner wants to undergo a workers’ compensation audit, but they are a fact of life if you run a business and have employees.

Unfortunately, many audits don’t go smoothly and sometimes your insurer may make mistakes. Missouri-based Workers’ Compensation Consultants, which helps employers through the workers’ comp audit process, recently listed the 10 most common audit mistakes that insurance companies make.

The list highlights a common problem and how you can detect the mistakes to avoid being stuck with a massive audit bill. Insurance companies allow you to review the audit with your broker. If you notice that you have received an audit bill that is obviously overstated, you should contact us.

Here are the things to look for when reviewing an audit by your insurance company:

Wrong class code – Misapplication of job classifications occurs in many workers’ comp audits. With hundreds of job classes to choose from, mistakes can happen. Talk to us and review your old policies to see if any of your class codes have changed.

X-Mod is changed – After your insurer finishes the audit, it will use the information to calculate your premium. When that happens, it has to include your X-Mod to get the right rate. But sometimes the insurer may use an incorrect X-Mod. Check carefully.

Subcontractors are counted – Sometimes insurers will include subcontractors as employees, which results in a new audit bill to account for the additional “employees.” But if they are genuine subcontractors, they should not be counted. Often, uninsured contractors will be included as employees. Make sure to use insured contractors only.

Disappearing credits – Most policies will have some sort of premium credits or other modifiers. Sometimes during audits, the insurer will remove them when recalculating the premium they think you owe. Watch out for missing credits and other modifiers if you get an audit bill, like:

  • Premium discount
  • Schedule credits
  • Deductible credits
  • State-specific credits

 

Audit worksheets missing – If the auditor fails to provide you with audit worksheets, which are used do compile your payroll and other audit information, you should ask to check their work. They will provide you with the information you need to carry out such a check.

Your rates changed – The rates you are charged at the beginning of your policy period must remain the same for the entire policy period. If your base rates have changed, the insurer may have made a mistake. 

Separation of payroll – Depending on your industry, you may or may not be able to split your employees’ payroll between job classifications (like cabinet installers and sheetrock hangers). This is a pinch point when errors can occur. If the auditor says you are not allowed to split job classifications even though you have in the past, your audit may be in error.

Unexpected large premium due – If you get a significant bill for your insurance company after your audit, the auditor may have made mistakes, particularly if you know that your employment has remained relatively stable and you’ve had no significant claims, if any. If it seems out of whack, call us.

Payroll data doesn’t match – If there is a discrepancy between your payroll data and what you see on the audit, a mistake may have been made. Try to match the payroll on the audit with that generated from your accountant. If the insurer made a mistake, you could end up paying for phantom payroll numbers.

No physical audit – There are three types of audits:

  • Mail audit
  • Phone audit, and
  • Physical audit

 

The mail and phone audits are prone to errors, since neither you nor your staff likely have any experience in premium auditing. If you have a big bill after a mail or phone audit, mistakes could have been made.

As Health Deductibles Rise, Employees More Likely to File Workers’ Comp Claims: Study

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Sometimes, injured employees are afraid to file a workers’ comp claim after being injured at work because they fear the specter of retaliation by their employer.

Experts suspect that up to 10% of workplace injuries are never reported because the workers choose to have the injuries covered by their employer-sponsored health plans. Most employers may not be aware of the full extent of their workplace injuries because of this phenomenon.

But, that could change as workers are saddled with higher deductibles and out-of-pocket expenses, according to a new study.

A number of past studies have found that if the costs to workers for having their personal health insurance cover a workplace injury is less than the “cost” to them of filing a workers’ comp claim, they will opt to have their health insurance cover it instead.

Here’s what studies have found over the years:

  • A 1996 study found that workers without health insurance have an incentive to claim their medical issues are work-related even if they are not, so that workers’ compensation insurance will pay for care. The study also found that if the injury occurs at work, health insurance may deter workers from filing for workers’ comp if they feel there is a cost to filing a claim.
  • A 2007 study found that a genuine workers’ comp claim can be “costly” to file for a worker if:
    • The employer dissuades workers from filing workers’ comp claims because they fear the claims will increase their premiums.
    • The injured worker does not want to deal with the paperwork for a workers’ comp claim.
    • The individual feels there is a stigma associated with filing for workers’ comp.
  • A 2003 study of Michigan workers and their physicians found that 70% of injured workers did not file for workers’ comp, and that 36% of the non-reporting injured workers cited having health insurance as a reason they did not.

What could be ahead

The most recent study, by the Workers’ Compensation Research Institute (WCRI), found that injured employees are more likely to file workers’ compensation claims when they have high-deductible group health plans.

The study found that workers with a remaining group health insurance deductible that exceeds $550 are more likely to file workers’ comp claims than if the deductible were less. As more workers find themselves staring at higher health insurance deductibles, they will properly report their workers’ comp claims to their employers.

“In years past, workers may have chosen to have a work injury covered within their group health plan,” John Ruser, WCRI president and CEO, said in a statement. “But the increasing cost of deductibles may cause them to consider having the injury covered ─ where it potentially belongs ─ in the workers’ compensation system, where there are no deductibles or copayments for the medical care they receive.”

This is likely to add about 5% more claims into the system, the WCRI found.

What you can do

There are risks to both your employee and your organization if a worker does not report their workplace injury.

Urge your workers to report any workplace injuries so that you can have them properly treated. If a worker decides to not report the claim and they have their health insurance pay for it, problems can take root and cause major issues for you later:

  • Your insurer loses the chance to direct the initial treatment to an occupational health clinic that specializes in treating workers’ compensation injuries and coordinates with the employer’s return-to-work program.
  • A delay in seeking treatment may cause a deterioration in the employee’s condition that will impede their recovery time.
  • It impedes the insurance company’s ability to investigate a claim, determine compensability and identify claims fraud.

New Rule Simplifies X-Mod Calculation, Encourages Reporting First Aid Claims

A new method for calculating workers’ compensation experience modifications (X-Mods) took effect in California on Jan. 1.

The Workers’ Compensation Insurance Rating Bureau of California has created a new simplified formula for calculating X-Mods as part of its efforts to add more transparency to the process. The new formula excludes the first $250 of every claim for the X-Mod computation, no matter how large or small the claim is.

This also means that if an employer pays, say, $200 for first aid on a minor workplace injury, they are required to report it as a claim. Doing so will not affect their X-Mod in any way, no matter how many first aid claims they have.

The goal is to encourage employers to report all claims, even those that may require minimal medical treatment or first aid.

Examples:

  • If you have a $10,000 primary threshold and you have a claim that ends up costing $6,000, the amount used to compute your X-Mod would be $5,750.
  • If you have a $10,000 primary threshold and you have a claim that ends up costing $17,000, the amount used for calculating your X-Mod would be $9,750.
  • If you have a claim that’s valued at $250 or less, the claim will still show on your experience rating worksheet, but it will not be used at all when calculating your X-Mod.

Does this affect your current X-Mod?

Yes. Any claim incurred against policies incepting during the experience period for your 2019 experience modification, which includes 2015, 2016 and 2017 policy years, will be used in the X-Mod computation at $250 less than its reported value.

Claims costing $250 or less will be shown on worksheets, but will not be used in X-Mod calculation.

Reporting first aid claims is required

Workers’ comp regulations require that all claims that cost some amount of money to treat must be reported to your workers’ comp carrier, which in turn must report to the Rating Bureau so that it can accurately keep workers’ comp records on employers that are experience rated.

The rules have already been on the books for years, but the problem of non-reporting became too great, so the Rating Bureau has stepped up to encourage employers to follow the rules. And in this case, it can’t work against you.

Workers’ Comp Rate Changes: What You Absolutely Need To Know

what you need to know about workers comp rate changesThere’s been a lot of confusion regarding upcoming changes for Workers’ Compensation rates and rightly so.  The Workers’ Compensation Insurance Rating Bureau of California wants to lower the current rate by 1.8% based on what businesses are currently being charged but last year the same bureau wanted to increase rates by around 27%. So which is it?

Continue reading “Workers’ Comp Rate Changes: What You Absolutely Need To Know”