Posted by Work Comp Data Solutions on Oct 22nd 2019

6 things the California Division of Workers’ Compensation Doesn’t Know.

You might think that with all the data that the Division of Workers’ Compensation (DWC) collects from you that they know EVERYTHING about every worker’s comp injury in California. But that is completely untrue. For the Division of Workers’ Compensation (DWC), there are at least 6 major blind spots when comes to understanding the itself and its injured workers.

6. The quality of care you are receiving in Medical Provider Networks (MPNs)

If you’ve been injured recently in California, chances are your care has been managed by a Medical Provider Network MPN) run by your claim’s administrator. However, DWC cannot tell whether the MPN system your claims administrator is making you visit provides quality care.

The collection of provider networks known MPNs are everywhere! To date there are more than 2,400 MPNs registered by DWC. However, because of systemic under-reporting to the WCIS medical billing database, DWC cannot provide effective oversight for the statewide MPN program or specific MPN programs run by specific claims administrators.

The MPN program, its requirements, and its pervasiveness in the system make it something DWC should fundamentally know about in great detail. As it stands now, the MPN program is not ready for evaluation, and until it is the quality of your healthcare is at risk.

5. What happens to claims that are denied.

Have you had your work comp case delayed or denied? If you’ve lived in California long enough, you have heard plenty of horror stories. However, DWC data collection efforts may not count your denial and show that DWC does not care about the story of your claim denial. If it did, it would know how many denials are in the system and it would be able to track any claim with a denial to know its ultimate disposition.

If you’re thinking “But wait!, the California system surely must be able to count the denials at least," would only be somewhat correct. DWC collects whether a claim is denied on the Workers’ Compensation Information Systems (WCIS) First Reports of Injury and Subsequent Reports of Injury (FROI/SROI).” However, this data collection effort falls short of the actual number of denials.  Comparisons with what the Audit Unit calculates that the basic denial is reported to WCIS at around 30 percent lower than what the Audit Unit receives. Further caveats to the WCIS and Audit Unit definition of denial hurt the actual count even more.

Even if there is a way to count, there is no way to tell from DWC's current data collection effort whether the denial stays on the claim forever, is lifted, or litigated.  Not knowing about claim denials and their history hurts DWC's ability to understand how its system impacts injured workers and Californian's trust in the system.

4. The amount of payments being made by public entities for workplace injuries.

Do you want to be on the hook for a major city or county bankruptcy? What the California DWC doesn’t know about the work comp being paid by our state, counties and cities puts all Californians at risk for a hefty bailout.

In 2016 ,WCIS reported at a stakeholder meeting that only 33 percent of public employer data is being sent in to the DWC. Without this data the amount of information DWC can reliably produce on the cost of public agency workers’ compensation is staggeringly low.  Not knowing the amount of money spent by cities, counties and other public agencies pay for their injured workers puts the public at risk blinds DWC to the true cost, quality and effectiveness of public workers’ compensation programs.  It also blinds them to possible missteps by public officials. 

This data gap until fixed will continue to hurt the public’s trust in the effectiveness of workers’ compensation programs for first responders, teachers and other public officials.  The people have a right to know what is being paid in work comp benefits, that the payment is on time to its first responders and that the payments will continue without interrupting other vital public programs.  

3. The number claims that are currently active in the California worker’s compensation system.

Do you know if you are still involved in California’s workers’ compensation system? Like a ghosted break-up, the DWC isn’t so sure. That is because as DWC doesn’t know the status of claims in the system.   DWC not knowing whether a claim is on-going or closed is a fundamental weakness that hurts everything they say when it comes to the impact of any program on claims.

Yes, DWC via WCIS does collect a claim status data element (DN 73) and does require a final (FN) or annual (AN) transaction, so in a perfect reporting world WCIS SROI would capture the claim status for all claims. However, SROI is not complete. According to its last update, SROI benefit reporting is only at 64%. In addition, SROI has a quirk in its reporting that only requires a triggering event to initiate a report. In English, this means that if no event takes place like a payment or a claim closure then the claim can sit open indefinitely*

If the DWC cannot effectively answer this cornerstone piece of the life-cycle of its claims, how can it make a judgment on the true cost of anything or the impact of anything? 

*There is an effort to clarify this problem in the proposed guide updates that were posted on the DWC forum, however as DWC has not started the formal rulemaking process, the updated FROI/SROI Guide is still more than 2 years away.

Not knowing a claim’s status is a major blind spot and it is made worse by number 2.

2. The number of injured workers, employers and providers there are currently in the system.

If you are part of the workers’ compensation system you know it is a massive system

There are a lot of people in California’s workers’ compensation. However, ask the DWC today, and they would not be able to tell you how many injured workers, employers and providers are currently active in the work comp system.

WCIS does collect the names of injured workers, employers, and providers, but it cannot produce with any clarity how many there are of each. This is mainly due to the collection method, which allows for names, SSNs, FEINs, and other registrations that are not verified and standardized. Variations on names, the system cannot account for very well and it creates havoc when attempting to count the number of claims an individual or employer has and the number of bills a provider has.

Compounded with the other blind spots this means DWC cannot track effectively what is currently happening in the system, how individual claimants were processed over the past decade or how many people have come back in the system after an initial injury For the better part of a decade, DWC and DIR have been attempting to rectify this with half measures and half solutions. There have been many false starts to data solutions but so far no results.

When a system like DWC cannot track the individuals and employers in its system very well, it is no wonder that DWC focuses on fee and utilization schedules, and grand non-direct solutions.  When was the last proposed regulation by DWC for employers and injured workers?  You are not going to get any until the DWC data machine is focused on the individual worker and employer experience with workplace injury.

1.  Number of people who die each year as a result of their workplace injury.

If you have ever known someone who was diagnosed and died from a work-related cancer, illness or disease these injuries you'd never forget them.  However, DWC doesn't know about them. DWC is often asked about benefits for the fatally injured, and death benefits for firefighter, peace officers and other public safety victims. However, DWC doesn’t know about it, and the number of people who die each year as a result of work injuries is the biggest blind spot for DWC. Knowing that workers did not survive work is the first thing, DWC and the DIR ‘California’s Labor Department’ should know about its workers. 

That being said, if asked today, DWC and DIR could not tell you how many people have died of work-related injuries in the past year, or decade. The best they can do is produce a report from their portion of the US Department of Labor’s (DOL) led Census for Fatal Occupation and illness report online and a DIR News Release. This report is not a complete record of fatalities in California, as it only shows the fatalities that occur as a result of a specific set of non cumulative injuries.  A known flaw for these reports is that they are missing from the injury types that are not included are every disease, cancer, and illness. Despite the known omission DWC is doing nothing to account for them.  

If you cannot record the deaths of California workers from illness and disease accurately then it is fundamentally impossible to right regulations to help prevent them.   

-----

If you would like to discuss this blog post, have a blind spot you would like to add, or would like to suggest further blog topics, please contact WCDS.