OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Duplicate Claims and Customers

Policy #:

CP-04-05

Code/Rule Reference:

None

Effective Date:

01/18/2019

Approved:

Kevin Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy and Procedure #CP-04-05, effective 11/14/16

History:

01/28/13

Rev. 1/15/2019; 08/01/2018

 

 

 

 

Duplicate Claims Policy and Procedure Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

IV. POLICY

V. PROCEDURE

A.          Standard Claim File Documentation

B.          Identifying Duplicate Claims

C.          Investigating and Processing Duplicate Claims  

D.          Investigating and Processing Duplicate Customers

E.          Combining and Decombining Claims

F.          Overpaid Compensation and Medical Bills

VI. Appendix A: Combining Duplicate Claims

 

 

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that duplicate claims are properly identified and combined in an efficient manner to prevent duplicate actions.

 

II. APPLICABILITY

 

This policy applies to all claims service staff and managed care organizations.

 

III. DEFINITIONS

 

Alias Claim: The claim that is combined into the surviving claim.

 

Duplicate Claim: When more than one claim exists with data fields that indicate the claims are for the same individual and the same accident or occupational disease event. Data fields may include, but are not limited to, the following:

a.    Same injured worker (IW) name;

b.    Social security number;

c.     Risk/policy number, and

d.    Date of injury.

 

Customer: Used within BWC’s claims management system, this term refers to the collection of personal or demographic information gathered regarding the claimant.  When a claim is filed, the “customer” record provides the claimant’s contact information. A customer record can also be created for a business, a representative or a provider.

 

Duplicate Customer: Multiple customer records existing in the claims or policy management system for the same person or business. Duplicate customers often occur due to inaccurate or missing tax identification information upon initial entry.

 

Surviving Claim: The claim that remains once the alias claims are combined.

 

IV. POLICY

 

It is the policy of BWC to identify and combine duplicate claims and duplicate customers in a manner that avoids overpayments and creates one complete and accurate claim.

 

V. PROCEDURE

 

A.    Standard Claim File Documentation

1.    BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note requirements; and

2.    Shall follow any other specific instructions for claim notes included in this procedure.

 

B.    Identifying Duplicate Claims

1.    During investigation and initial determination of a claim, the assigned claims service staff shall review the claims management system to determine if possible duplicate claims exist.

2.    Claims may be considered duplicate when they contain the following identical elements:

a.    IW’s name;

b.    Risk/policy number;

c.     Date of occurrence and accident description.

3.    Claims containing no social security number (SSN) or the same SSN are only considered to be duplicate when they also contain all the data elements in B.2. above.

4.    Duplicate claims and duplicate customer may be identified through the following:

a.    An Industrial Commission (IC) order;

b.    Notification from the MCO;

c.     A name and social security review conducted by claims service staff;

d.    The Automatic Claims Processing (ACP) Potential Dupe Same Policy flag; or

e.    A duplicate claims report that has been posted to the IMS/EMS SharePoint Cognos Reports folder.

f.      Parties of the claim

 

C.   Investigating and Processing Duplicate Customers (see Appendix A below for the variations that can occur with duplicate customers)

1.    Prior to resolving duplicate claims issues, claims service staff shall determine if a duplicate customer record exists.

2.    If a duplicate customer is discovered, claims service staff shall determine which customer’s information is correct and address the discrepancy.

3.    If the customer record for the IW in which the error(s) occurred contains more than one claim for the IW, claims service staff must review all claims attached to that customer record and move all of the claims to the remaining viable customer record before flagging the incorrect customer records as “DO NOT USE”.

4.    Once the discrepancies are reconciled, one customer record will be the surviving customer and one shall be updated to reflect “Do Not Use” and have a Block set for “invalid customer.”

5.    The BWC Duplicate Claims/Duplicate Customer  PowerSuite job aid provides detailed steps on how to process duplicate customer issues.

 

D.   Investigating and Processing Duplicate Claims (see Appendix A below for the variations that can occur with duplicate claims)

1.    After resolving duplicate customer issues, claims service staff shall investigate indicators of potential duplicate claims as referenced in section B above.

2.    When duplicate claims have different employers, claims service staff shall investigate to determine the correct employer for each claim.

a.    If the investigation reveals that two employers employed the IW and the accident descriptions are different, then claims service staff shall process the claims separately.

b.    If the investigation reveals that both claims should have the same employer, and the claims are duplicates in all other respects, claims service staff shall:

i.      Make the employer correction following the procedures outlined in the Initial Claim Determination procedures if the claim with the incorrect employer has not yet been determined; or

ii.     Make the employer correction following the procedures outlined in the Changing the Employer and or Policy Number after Initial Determination procedures if the claim with the incorrect employer has been determined; then,

iii.    Refer to the Appendix A below to determine the appropriate action.  

iv.   Notify the identified employers of the findings.

3.    Possible duplicate claims that have different accident types (injury, occupational disease or death).

a.    If potentially duplicate claims with different accident types have been allowed, claims service staff shall discuss potential continuing jurisdiction with their claims supervisor and their BWC attorney.

b.    If the potentially duplicate claims with different accident types have not been determined, claims service staff shall investigate to determine the appropriate accident type, make a determination and then refer to the Appendix A below for further action.

 

E.    Combining and Decombining Claims

1.    Claims service staff shall combine verified duplicate claims in the claims management system pursuant to the instructions in the Duplicate Claims/Duplicate Customer PowerSuite job aid available on the Duplicate Claims policy page on COR.

2.    Claims service staff shall always review the customer records of all possible duplicate claims prior to combining the claims.

3.    Claims shall be combined into the earlier filing date, unless:

a.    Compensation has been, or is being paid in one claim and not the other. The claims shall be combined into the claim in which compensation has been paid;

b.    The IC has issued an order outlining how claims service staff shall combine the claims;

c.     Both claims were filed within the statute of limitations and circumstances make it more efficient to combine the claim into the later filed claim. (e.g., one claim has more information than its duplicate; the claim may be combined into the claim with the most complete information).

d.    Compensation is paid in more than one claim. 

i.         If duplicate records exist, claims service staff shall select the claim that has the most compensation paid as the surviving claim.

ii.       Claims Service  staff shall stop compensation in the alias claim(s), send a subsequent order and adjust compensation in accordance with the Adjustment of Overpaid Compensation policy and procedure.

4.    When combining duplicate claims, claims service staff shall confirm that the alias claim(s) is properly associated with the surviving claim.

5.    Claims service staff shall decombine claims when the following occurs:

a.    The IC orders it; or

b.    Claims service staff combines claims in error. A BWC order is not required.

 

F.    Overpaid Compensation and Medical Bills

1.    If claims service staff identifies an overpayment of compensation because of claim duplication, claims service  staff shall follow the procedures set forth in the Adjustment of Overpaid Compensation policy and procedures. Claims service staff shall not combine duplicate claims until the subsequent order is issued and appeal period expires.

2.    If claims service staff identifies an overpayment of medical bills because of claim duplication, claims service staff shall follow the procedures set forth in the Medical Recovery-Medical Bill Adjustments policy and procedure.

 

 

 

 

VI. Appendix A: COMBINING DUPLICATE CLAIMS

·         Claims may be considered duplicate when they have the same claimant name and/or risk/policy number.

·         Date of occurrence and accident description: Claims containing no social security number (SSN) or the same SSN are only considered to be duplicate when they also contain the same claimant name and/or risk/policy number.

·         Claims service staff must also review the customer records on the possible duplicate claims prior to addressing the combing claims.

Claim Status and Claim Status Reason

Combine?

Note

Both claims in pending status

Yes

If the accident and time of injury are the same, claims service staff will combine the claims.

One claim in accepted status and one in pending claim status

Yes

An investigation must be conducted to determine if the accident and time of injury are the same. If the accident and time of injury are the same, claims service staff will combine the new claim into the allowed claim.

One claim in denied status and one in pending claim status or accept/appeal

No

If the accident and time of injury are the same, then the claims may fit the “Greene Court Case” fact pattern.

One claim accepted and one claim denied

No

Staff with BWC attorney for continuing jurisdiction.

Two accepted claims

Yes

Claims service staff may combine the claims only if the parties agree to it and if the accident and time of injury are the same. If the parties do not agree to have the claims combined, the claim shall be staffed with the BWC attorney for continuing jurisdiction.

One claim in accept/appeal status and one is deny/appeal status

Yes

If no appeals are filed and if the accident and time of injury are the same, claims service staff will issue a vacate order, in alias claim only. The order must vacate the previous order and explain that the claims will be combined. The claims will be combined after the expiration of the appeal period.

One claim accepted and one either accept/appeal or deny/appeal

Yes

If no appeals are filed and if the accident and time of injury are the same, claims service staff will vacate the order of the claim in the appeal period and issue a modified order. The modified order must explain the claims will be combined. Upon the expiration of the appeal period, the claims will be combined.

One claim dismissed and one pending claim

Yes

Contact IW to determine if they want to dismiss the new claim or move forward. If they want to move forward, combine into the dismissed claim and issue a decision.

One claim dismissed and one accepted or denied

Yes

Combine the dismissed claim into the claim that has been determined.

One claim dismissed and one either accept/appeal or deny/appeal

Yes

If no appeals are filed and if the accident and time of injury are the same, claims service staff will vacate the order of the claim in the appeal period and issue a modified order. The modified order must explain the claims will be combined. Upon the expiration of the appeal period, the dismissed claim will be combined into the determined claim provided there are no appeals.

One claim is in hearing status and one claim is in one of the other statuses

No

Staff with the BWC attorney for continuing jurisdiction. Do not combine until after the IC decision is issued.