The delivery system: administrative supervision; notice requirements; audit procedures; anti-fraud legislation; injury prevention programs; information and assistance program; new SB 863 organizations

• Author: David L. Pollak/Roger A. Tolman, Jr./Monika R. Reyes
• Pages: 793-848

THE DELIVERY SYSTEM

14-1

CHAPTER 14

THE DELIVERY SYSTEM:

Administrative Supervision; Notice Requirements; Audit

Procedures; Anti-Fraud Legislation; Injury Prevention Programs;

The Information and Assistance Program; SB 863 Organizations

I. BACKGROUND

§14:01 The Ideal Agency

§14:02 1966 California Reorganization

§14:03 Division of Industrial Accidents Renamed as Division of Workers’ Compensation

§14:04 “Centrally Located City”

§14:05 DWC Regional Off‌ices and Satellite Off‌ices; DWC or WCAB?

§14:06 WCAB Judicial Functions

II. DIVISION OF WORKERS’ COMPENSATION

§14:20 Introduction; Rulemaking History; Administrative Changes

§14:21 Disability Evaluation Unit

§14:22 Rehabilitation Unit Abolished 1/1/09

§14:23 Information and Assistance Unit

§14:24 Claims Adjudication Unit

§14:25 Audit and Enforcement Unit

§14:26 Medical Unit

§14:27 Research Unit; Research Studies; “Carve-Out” and WCIS Supervision

§14:28 Retraining and Return to Work Unit

§14:29 Special Funds Unit

§14:30 Electronic Adjudication Management System (EAMS) and EDEX; Public Case Search Information

§14:31 Disability Accommodation Services

§14:32 Former Bureaus Within the Division

§14:33 “User Funding”

§14:34 Organizations and Entities Created in 2013 by SB 863

§14:35 Annual Educational Conference Sponsored by DWC

§14:36 Claims Educational Regulations Per Ins.Code §11761

§14:37 2017 Anti-Fraud Unit

III. NOTICE REQUIREMENTS: “PREINJURY NOTICES” TO ALL EMPLOYEES

§14:40 Posted Notices Required

§14:41 Consequences of Noncompliance

§14:42 Notice Re: Off-Duty Recreational, Social or Athletic Activity

§14:43 Notices Required Upon Hiring of Employees

THE DELIVERY SYSTEM

California Workers’ Compensation 14-2

IV. BENEFIT NOTICE REQUIREMENTS

A. General Points

§14:50 Background – 1965 Study Commission Report

§14:51 Administrative Supervision; Other AD Obligations re Notices

§14:52 Notice Requirements: “Time-Loss Injuries”; Ef fect of Notices

B. When Notices Must Be Sent

§14:60 General Requirements

§14:61 Temporary Disability Notices

§14:62 Permanent Disability Notices

§14:63 Notices to Dependents in Death Cases

§14:64 Change of Rate Notice

§14:65 Denial Notices

§14:66 Delay Notice

C. Corrections; Supervision; First Payment

§14:80 Corrected Notice

§14:81 Administrative Supervision

§14:82 Promptness of First Payment

D. Sanctions for Noncompliance With Benef‌it Notice Rules

§14:90 Legislative: Self-Imposed Penalty for Late Payment

§14:91 Judicial: Statute of Limitations

§14:92 Administrative Penalties

V. OTHER POSTINJURY NOTICES: LABOR STATISTICS REPORTS; DEATH NOTICES

A. Notice to Employee

§14:100 Conf‌licting Requirements Repealed

§14:101 Notice to Employee Victim of Workplace Crime

B. Employer, Labor Statistics and Research, OSHA and Doctor Reporting Requirements

§14:110 Employer’s Reports to Carrier

§14:111 Reports to Division of Labor Statistics and Research

§14:112 Insurer Report to Employer

§14:113 Doctor’s First Report

§14:114 Computerized Forms

§14:115 “Serious Injury” OSHA Report – Death

§14:116 Conf‌identiality and Admissibility of Reports

§14:117 Sanctions for Non-Compliance With Reporting Requirements

§14:118 Employer Records of Occupational Injury or Illness

§14:119 Electronic Data Reporting Requirements

C. Notices Required Upon Death of Employee

§14:130 Death Following Employer Report of Injury

§14:131 Industrial Death With Surviving Dependents

§14:132 Death Without Dependents

VI. INJURY PREVENTION PROGRAMS

§14:140 Employer’s Duties

§14:141 Carrier’s Responsibilities: Targeting Substantial Risks

§14:142 Government’s Responsibilities Re Hazardous Employment

§14:143 The Commission on Health, Safety and Workers’ Compensation (CHSWC)

VII. DWC AUDIT AND PENALTY AUTHORITY

A. AD Audit Responsibilities

§14:150 Prior Law

§14:151 Creation of Audit Unit; Prior and Current Audit Unit Procedures

§14:152 Examples of Audit Referrals

B. Claim File and Claim Log Maintenance

§14:160 Introduction

§14:161 Reserved

§14:162 Claim File Contents for Post-1/1/94 Injuries

§14:163 Retention of Claim Files

THE DELIVERY SYSTEM

14-3 The Delivery System

C. Claim Log Maintenance

§14:170 Introduction

§14:171 Annual Report of Inventory

D. The Audit Process

§14:180 Selection of Audit Subjects

§14:181 “Target Audits” for Poor Performers

§14:182 Audit Notice

§14:183 The Audit

§14:184 Claims Administrator’s Failure to Investigate Injury Claim

§14:185 Data Subject to Audit

§14:186 General Rules Re Audit Violations

E. Compensation Due

§14:200 Notice of Compensation Due

§14:201 Board Appeal of Notice of Compensation Due

F. Administrative Penalties

§14:210 Grounds for Administrative Penalty

§14:211 Amount of Penalty

G. Schedule for Administrative Penalties

§14:220 Schedule of Penalties

§14:221 Audit Unit Investigations Under LC §5814.6

§14:222 Utilization Review Audits

H. Penalty Assessment, Appeal, and Limit

§14:230 Penalty Assessment Procedures

§14:231 Appeal of Penalty or Indemnity Assessment

§14:232 $100,000 Civil Penalty

I. Civil Penalt y Procedures

§14:240 Order to Show Cause

§14:241 AD Hearing

§14:242 AD Determination; Appeal Process

VIII. ANTIFRAUD LEGISLATION

§14:250 False Compensation Claims – Felony; Fraudulent Claims by Medical Providers

§14:251 Compensation Barred; Applicable Restrictions

§14:252 Reporting Fraud

§14:253 Effect of Criminal Proceeding on Board and Vice Versa

§14:254 Restitution

§14:255 Fraud Admonishment on Pleadings and Reports; Fraud Warnings

§14:256 “Reconsideration” of Fraud-Tainted Board Award

§14:257 Bureau of Fraudulent Claims

§14:258 Prohibited Attorney or Physician Conduct

§14:259 Prohibited Medical Referrals

§14:260 Prohibited Kickbacks

§14:261 Civil Penalties for Fraud and Kickbacks

§14:262 Truth in Advertising: Enabling Legislation

§14:263 Truth in Advertising: Administrative Regulations

§14:264 Fraud Statutes Also Apply to Employers

IX. INFORMATION AND ASSISTANCE PROGRAM

§14:270 Background

§14:271 Information and Assistance Off‌icers

§14:272 “Assistance” Service

§14:273 Reference for Medical Examination

§14:274 Litigated Matters

§14:275 Conciliation Service and Recommendations

§14:276 Authority to Order Exchange of Documents

§14:277 The Recommendation

§14:278 Statute of Limitations Tolled

§14:279 Reserved