California Regulations 10107.1 725

From Wcc
Jump to: navigation, search

California > Regulations

§ Notice of Audit; Claim File Selection; Production of Claim Files; Auditing Procedure



For audits conducted on or after January 1, 2003:


(a) Once a subject has been selected for an audit, the Audit Unit shall serve a Notice of Audit on the claims administrator. The Notice shall inform the administrator of its selection for audit, and may include a request to provide the Audit Unit with a claim log or logs. If the Audit Unit has requested claim logs, the audit subject shall provide two copies of the specified claim log(s) within fourteen days of the date of the receipt of the Notice.


(b) At least 14 days before the audit is scheduled, the Audit Unit shall send the audit subject a Notice of Audit Commencement identifying the claims to be audited. The audit shall commence no less than fourteen days from the date the Notice was sent, unless the audit subject and Audit Unit agrees to earlier commencement.


(c) For profile audit reviews conducted pursuant to Labor Code Section 129(b)(1), the Audit Unit shall randomly select samples of indemnity claims from the most recent three years of the audit subject's claim logs or from the list of claims for those years as reported to the Division of Workers' Compensation pursuant to Labor Code Section 138.6 as part of the Workers' Compensation Information System. If any of the years have been the subject of a previous audit, claims will be randomly selected from the most recent unaudited year(s).


(1) The initial number of indemnity claims randomly selected for audit will be determined based on the following table:


Population ………. Sample Size


5 or less ………. all

6 – 10……….1 less than total

11 – 13……….2 less than total

14 – 16……….3 less than total

17 – 18……….4 less than total

19 – 20……….5 less than total

21 – 23……….6 less than total

24……….17

25 – 26……….18

27 – 29……….19

30 – 31……….20

32 – 33……….21

34 – 36……….22

37 – 39……….23

40 – 41……….24

42 – 44……….25

45 – 48……….26

49 – 51……….27

52 – 55……….28

56 – 58……….29

59 – 62……….30

63 – 67……….31

68 – 72……….32

73 – 77……….33

78 – 82……….34

83 – 88……….35

89 – 95……….36

96 – 102……….37

103 – 110……….38

111 – 119……….39

120 – 128……….40

129 – 139……….41

140 – 151……….42

152 – 164……….43

165 – 179……….44

180 – 197……….45

198 – 217……….46

218 – 241……….47

242 – 269……….48

270 – 304……….49

305 – 346……….50

347 – 399……….51

400 – 468……….52

469 – 562……….53

563 – 696……….54

697 – 905……….55

906 - 1,272……….56

1,273 - 2,091……….57

2,092 - 5,530……….58

5,531 +……….59



(2) In addition to the randomly selected indemnity claims, the Audit Unit may audit any claims for which it has received a complaint or information indicating a failure to pay indemnity, including any companion claim needed to ascertain the extent to which benefits have been provided.


(3) After reviewing the claims selected pursuant to subsection (1), the Audit Unit shall calculate the audit subject’s profile audit review performance rating based on its review of the randomly selected claims. The profile audit review performance rating will be calculated as follows:


(A) The factor for the failure to pay accrued and undisputed indemnity shall be determined by

(i-a) Dividing the number of randomly selected claims violations involving the failure to pay indemnity by the number of randomly selected claims with accrued and payable indemnity, whether paid or not, to produce a frequency rate.

(i-b) Dividing the total amount of unpaid indemnity in randomly selected claims by the number of randomly selected claims with accrued and payable indemnity, whether paid or not, to produce an average amount of unpaid indemnity per file with the obligation to pay indemnity.

(i-c) Dividing the average amount of unpaid indemnity per randomly selected audited claim with the obligation to pay indemnity for the audit subject by the average amount of unpaid indemnity per randomly selected audited claim for all audit subjects for the three calendar years before the year in which the current audit is being conducted, to produce a severity rate.

(i-d) Multiplying the frequency rate by the severity rate by a modifier of 2 to determine the factor for the failure to pay accrued and undisputed indemnity.


(ii) The factor for the late first payment of temporary disability indemnity and issuance of first temporary disability notices shall be determined by dividing the number of randomly selected claims with violations involving the late first payment of temporary disability indemnity, or in claims that involve salary continuation in lieu of first temporary disability payments, the late issuance of the first temporary disability notice by the number of randomly selected claims in which temporary disability payments or first temporary disability notices were issued.


(iii) The factor for the late first payment of permanent disability indemnity, vocational rehabilitation maintenance allowance, and death benefits shall be determined by dividing the numbers of randomly selected claims with violations involving late first payments of those benefits by the numbers of randomly selected claims with payments for those benefits. In calculation of this factor, claims shall be counted for each type of exposure and late first payment.


(iv) The factor for late subsequent indemnity payments shall be determined by dividing the number of randomly selected claims with violations involving late indemnity payments subsequent to first payment by the number of randomly selected claims with subsequent indemnity payments.


(v) The factor for failure to comply with requirements for notices advising injured employees of the process for selecting Agreed Medical Examiners and/or Qualified Medical Examiners once the employees' injuries have reached a permanent and stationary status, and for failure to comply with the requirements for notices advising injured workers of potential eligibility for vocational rehabilitation pursuant to Labor Code Section 4637 shall be determined by dividing the numbers of randomly selected claims with violations involving the failure to issue the notices by the numbers of randomly selected claims with the requirement to issue the notices. In calculation of this factor, claims shall be counted for each type of exposure and violation.


(vi) The audit subject's profile audit review performance rating will be determined by adding the factors calculated pursuant to subsections (c)(3)(A)(i) through (c)(3)(A)(v).


(B) If the audit subject's profile audit review performance rating meets or exceeds the worst 20% of performance ratings for all final audit reports issued over the three calendar years before the year preceding the current audit, the Audit Unit will issue Notices of Compensation Due pursuant to Section 10110 but will assess no administrative penalties for violations found in the profile audit review.

(C) If the audit subject's profile audit review performance rating fails to meet or exceed the rating of the worst 20% of performance ratings as calculated based on all final audit findings as published in the Annual DWC Audit Reports over the three calendar years before the year preceding the current audit, the Audit Unit will conduct a Full Compliance Audit by randomly selecting and auditing an additional sample of indemnity claims pursuant to subsection (d). Written notification of the Audit Unit’s intent to proceed to a Full Compliance Audit, showing the calculation of the profile audit review performance rating, will be provided to the audit subject in time for the timely filing of an objection. The audit subject may dispute whether or not a Full Compliance Audit is merited under this subsection at a post-profile audit review conference. Following the post-profile audit review conference, the Audit Unit may continue with the Full Compliance Audit. The audit subject may appeal the issues pursuant to Section 10115.1 following the issuance of the final audit report. Failure of the audit subject to raise issues related to failing to meet or exceed the profile audit review performance standard during the post-profile audit review conference shall constitute a waiver of appeal on those issues.



(d) If the audit subjects fails to meet or exceed the profile audit review performance standard, the Audit Unit shall conduct a Full Compliance Audit by selecting and auditing an additional sample of indemnity claims.


(1) The total number of indemnity claims randomly selected for audit, including the number audited pursuant to subsection (c)(1), will be determined based on the following table:


Population ………. Sample Size


8 or less………. all

9 – 15………. 1 less than total

16 – 19………. 2 less than total

20 – 23………. 3 less than total

24 – 27………. 4 less than total

28 – 30………. 5 less than total

31 – 33………. 6 less than total

34 – 36………. 7 less than total

37 – 38………. 8 less than total

39 – 41………. 9 less than total

42 ………. 32

43 – 44………. 33

45 ………. 34

46 – 47………. 35

48 – 49………. 36

50 – 51………. 37

52 – 53………. 38

54 – 55………. 39

56 – 57………. 40

58 – 59………. 41

60 – 61………. 42

62 – 63………. 43

64 – 65………. 44

66 – 67………. 45

68 – 70………. 46

71 – 72………. 47

73 – 74………. 48

75 – 77………. 49

78 – 79………. 50

80 – 82………. 51

83 – 84………. 52

85 – 87………. 53

88 – 89………. 54

90 – 92………. 55

93 – 95………. 56

96 – 98………. 57

99 – 101………. 58

102 – 104………. 59

105 – 107………. 60

108 – 110………. 61

111 – 114………. 62

115 – 117………. 63

118 – 120………. 64

121 – 124………. 65

125 – 128………. 66

129 – 131………. 67

132 – 135………. 68

136 – 139………. 69

140 – 143………. 70

144 – 148………. 71

149 – 152………. 72

153 – 156………. 73

157 – 161………. 74

162 – 166………. 75

167 – 171………. 76

172 – 176………. 77

177 – 181………. 78

182 – 187………. 79

188 – 192………. 80

193 – 198………. 81

199 – 204………. 82

205 – 210………. 83

211 – 217………. 84

218 – 223………. 85

224 – 230………. 86

231 – 238………. 87

239 – 245………. 88

246 – 253………. 89

254 – 261………. 90

262 – 270………. 91

271 – 279………. 92

280 – 288………. 93

289 – 298………. 94

299 – 308………. 95

309 – 319………. 96

320 – 330………. 97

331 – 342………. 98

343 – 354………. 99

355 – 367………. 100

368 – 381………. 101

382 – 396………. 102

397 – 411………. 103

412 – 427………. 104

428 – 444………. 105

445 – 463………. 106

464 – 482………. 107

483 – 503………. 108

504 – 525………. 109

526 – 549………. 110

550 – 575………. 111

576 – 603………. 112

604 – 633………. 113

634 – 665………. 114

666 – 700………. 115

701 – 739………. 116

740 – 781………. 117

782 – 827………. 118

828 – 879………. 119

880 – 936………. 120

937 - 1,000………. 121

1,001 - 1,072………. 122

1,073 - 1,154………. 123

1,155 - 1,248………. 124

1,249 - 1,356………. 125

1,357 - 1,483………. 126

1,484 - 1,633………. 127

1,634 - 1,814………. 128

1,815 - 2,036………. 129

2,037 - 2,315………. 130

2,316 - 2,677………. 131

2,678 - 3,163………. 132

3,164 - 3,852………. 133

3,853 - 4,904………. 134

4,905 - 6,710………. 135

6,711 - 10,530………. 136

10,531 - 23,993………. 137

23,994 +………. 138


(2) In addition to the randomly selected indemnity claims, the Audit Unit may audit any claims for which it has received a complaint or information indicating a failure to pay indemnity or late-paid indemnity, including any companion claim needed to ascertain the extent to which benefits have been provided.


(3) After reviewing the claims selected pursuant to subsection (1), the Audit Unit shall calculate the audit subject’s full compliance audit performance rating.


(A) The audit subject’s full compliance audit performance rating will be calculated pursuant to subsection (c)(3)(A), except that it shall be based on the review of all claims selected pursuant to subsection (d)(1).


(B) If the audit subject's full compliance audit performance rating meets or exceeds the worst 10% of performance ratings for all final audit reports issued over the three calendar years before the year preceding the current audit, the Audit Unit will issue Notices of Compensation Due pursuant to Section 10110 and will assess administrative penalties only for violations involving unpaid and late paid compensation, pursuant to Labor Code Section 129.5(c)(2).


(e) If the audit subject's full compliance audit performance rating fails to meet or exceed the rating of the worst 10% of performance ratings for all final audit reports issued over the three calendar years before the year preceding the current audit, the Audit Unit will audit all claims selected for audit for all violations, and also randomly select a sample of denied claims.Notification of the Audit Unit’s intent to audit a sample of denied claims and assess penalties pursuant to Labor Code Section 129.5(c)(3) will be provided to the audit subject based on findings at a meet and confer audit review conference. At that time the audit subject may dispute whether or not it met or exceeded the Full Compliance Audit performance standard. Following the meet and confer audit review conference, the Audit Unit may continue with the Full Compliance Audit. The audit subject may appeal pursuant to Section 10115.1 following the issuance of the final audit report. Failure of the audit subject to raise issues related to failing to meet or exceed the full compliance audit performance standard during the meet and confer audit review conference shall constitute a waiver of appeal on those issues.


(1) The number of denied claims randomly selected for audit will be based on the following table:


Population ………. Sample Size


6 or less.......... all

7 – 10.......... 1 less than total

11 – 14.......... 2 less than total

15 – 17.......... 3 less than total

18.......... 14

19 – 20.......... 15

21.......... 16

22 – 23.......... 17

24 – 25.......... 18

26 – 27.......... 19

28 - 29.......... 20

30 - 31.......... 21

32 - 33.......... 22

34 - 36.......... 23

37 - 38.......... 24

39 - 41.......... 25

42 - 43.......... 26

44 - 46.......... 27

47 - 49.......... 28

50 - 52.......... 29

53 - 55.......... 30

56 - 59.......... 31

60 - 63.......... 32

64 - 67.......... 33

68 - 71.......... 34

72 - 75.......... 35

76 - 80.......... 36

81 - 85.......... 37

86 - 90.......... 38

91 - 96.......... 39

97 - 102.......... 40

103 - 109.......... 41

110 - 116.......... 42

117 - 124.......... 43

125 - 132.......... 44

133 - 141.......... 45

142 - 151.......... 46

152 - 163.......... 47

164 - 175.......... 48

176 - 189.......... 49

190 - 205.......... 50

206 - 222.......... 51

223- 242.......... 52

243 - 265.......... 53

266 - 292.......... 54

293 - 323.......... 55

324 - 360.......... 56

361 - 405.......... 57

406 - 461.......... 58

462 - 531.......... 59

532 - 623.......... 60

624 - 749.......... 61

750 - 931.......... 62

932 – 1,217.......... 63

1,218 – 1,731.......... 64

1,732 – 2,934.......... 65

2,935 – 8,990.......... 66

8,991 +.......... 67


(2) In addition to the random samples of indemnity and denied claims and claims for which the Division received complaints or information indicating unpaid or late-paid compensation, the Audit Unit may select for audit any claims for which it received complaints or information over the past three years that indicate the possible existence of any claims handling violations.


(f) Following the conclusion of the audit, the Audit Unit shall issue a report of audit findings which may include, but is not limited to, the following: one or more requests for additional documentation or compliance, Notices of Intention to Issue Notice of Compensation Due, Preliminary Notices of Penalty Assessments, Notices of Compensation Due, or Notices of Penalty Assessments. If any additional requested documentation is not provided within thirty days of receipt of the report, additional audit penalties may be assessed under Section 10111.1(d)(2) of these Regulations.


(g) The audit subject shall pay all expenses of an audit of an adjusting location outside the State of California, including per diem, travel expense, and compensated overtime of audit personnel.


(h) The audit subject shall make each of the claim files selected for audit available at the audit site at the time of audit commencement. If claim files are maintained in an electronic or other non-paper storage medium, the claims administrator shall, upon request, provide to the Audit Unit direct computer access to electronic claim files and/or legible printed paper copies of the claim files, including all records of compensation payments. If a randomly selected indemnity, medical-only, or denied claim has been incorrectly classified as to type by the audit subject, the Audit Unit may randomly select an additional correctly designated claim file for audit, and may also assess penalties as appropriate in the misdesignated claim initially selected. If the audit subject fails to produce a claim selected for audit, the Audit Unit may assess a penalty for failure to produce the claim pursuant to Section 10111.2(b)(3) and may also select for audit another claim of the same type to complete the random sample. If the audit subject has transferred a claim selected for audit to a different adjusting location of the company being audited, the audit subject shall nonetheless produce the claim for audit within five working days of request, unless additional time is agreed upon by both the Audit Unit and the audit subject.


(i) The Audit Unit shall have discretion to audit claims in addition to those identified with the Notice of Audit Commencement. The audit subject shall make each of the additional claims selected for audit available at the audit site as follows:

(1) Open claims and closed claims stored on site within one working day of request;

(2) Closed claims stored off site within five working days of request, unless additional time is agreed upon by both the Audit Unit and the audit subject.


(j) The audit subject shall provide the auditor(s) an adequate, safe, and healthful workspace during the audit, which allows the auditors a reasonable degree of privacy. If this workspace is not provided, the Audit Unit may require the audit subject to deliver the files to the nearest Audit Unit office for completion of the audit.


(k) The Audit Unit may obtain and retain copies of documentation or information from claim files to support the assessment of penalties.


(l) The audit subject shall have the opportunity to discuss preliminary findings and provide additional information at a post-audit conference.


(m) The Audit Unit may at any time request additional information or documentation related to the claims being audited in order to complete its audit. Such information may include documentation that, as specified by Labor Code Sections 3751(a) and 3752, compensation has not been reduced or affected by any insurance, contribution, or other benefit due to or received by or from the employee. The audit subject shall provide any requested documentation or other information within thirty days from the Audit Unit's request, unless the Audit Unit extends the time for good cause.


Note: Authority cited: Sections 59, 129.5, 133, 5307.3, Labor Code. Reference: Sections 11180, 11180.5, 11181, and 11182, Government Code. Sections 111, 124, 129, 129.5, 3751 and 3752, Labor Code.

New Regulation added effective 1/1/03.