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California’s Division of Workers’ Compensation (DWC) Announces 2019 Profile Audit Review and Full Compliance Audit Performance
By Lonce Lamonte and DIR DWC Newsline - November 19, 2018

Labor Code sections 129 and 129.5 require the Audit and Enforcement Unit of the Division of Workers’ Compensation (DWC) to conduct a profile audit review (PAR) for all adjusting locations of California workers’ compensation claims at least once every five years.

Performance of the adjusting locations is measured in five areas of claims administration:

  • The payment of accrued and undisputed indemnity
  • The late first payment of temporary disability / first notice of salary continuation
  • The late first payment of permanent disability and death benefits
  • The late subsequent indemnity payments
  • The provision of notices with Qualified Medical Evaluator/Agreed Medical Evaluator advice.

DWC annually establishes profile audit review and full compliance audit (FCA) standards in accordance with Labor Code sections 129(b)(1) and (2) and California Code of Regulations, title 8 (8 C.C.R.), section 10107.1. The 2019 standards are based on the audit results of calendar years 2015 through 2017.

Performance standards for 2019

The PAR performance standard for audits conducted in 2019 is 1.36133. Audit subjects with PAR performance ratings of 1.36133or lower will be required to pay any unpaid compensation, but no administrative penalties will be assessed. If an audit subject’s PAR performance rating is 1.36134 or higher, the audit will expand to a FCA, and an additional sample of indemnity claims will be audited.

The FCA performance standard for audits conducted in 2019 is 1.66166. Audit subjects with an FCA performance rating of 1.66166or less will be required to pay any unpaid compensation and administrative penalties will be assessed for all violations involving unpaid and late paid compensation. If an audit subject’s full compliance audit performance rating is 1.66167 or higher, an additional sample of denied claims as well as the expanded sample of indemnity claims will be audited. Penalties will be assessed for all violations as appropriate pursuant to 8 C.C.R. sections 10111 through 10111.2.

Severity Rate standard for 2019

The Severity Rate standard for 2019 is $104.97.

More information on the performance standards that will be in use for the profile audit reviews and full compliance audits during calendar year 2019 will be posted on the DWC Audit and Enforcement Unit web page.

 

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Lonce Lamonte, journalist, lonce@adjustercom.com in coordination with DIR’s Newsline.  www.dir.ca.gov

 

 
 

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