OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Duplicate Claims and Customers

Policy #:

CP-04-05

Code/Rule Reference:

None

Effective Date:

11/05/2021

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

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

History:

Previous versions of this policy are available upon request


 

Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

IV. POLICY

V. PROCEDURE

A.          General Claim Note and Documentation Requirements

B.          Identifying Duplicate Claims

C.         Investigating/Processing Duplicate Customers

D.         Investigating/Processing Duplicate Claims

E.          Duplicate claims that have different accident types (injury, occupational disease or death)

F.          Combining and Decombining Claims

G.         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 BWC 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 has the same injured worker name, social security number, risk/policy number, and date of injury.

 

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 in a manner that avoids or corrects overpayments and creates one complete and accurate claim.

 

V. PROCEDURE

A.     General Claim Note and Documentation Requirements

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

 

B.     Identifying Duplicate Claims

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

a.     Injured Worker’s name;

b.     Social security number;

c.      Risk/policy number;

d.     Date of occurence.

2.     Duplicate claims may be identified as follows:

a.     The claims management system provides an alert of a duplicate or potential duplicate claim;

b.     An Industrial Commission (IC) order identifies one or more claims as duplicate;

c.      BWC staff identifies a potential duplicate while conducting a name and social security review;

d.     Notification from the MCO;

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

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

g.     Parties to the claim.

 

C.    Investigating/Processing 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 CoreSuite job aid provides detailed steps on how to process duplicate customer issues.

 

D.    Investigating/Processing Duplicate Claims

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

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

3.     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.

4.     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:

a.     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

b.     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,

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

d.     Notify the identified employers of the findings.

 

E.     Duplicate claims that have different accident types (injury, occupational disease or death)

1.     If potentially duplicate claims with different accident types have been allowed, BWC staff shall discuss potential continuing jurisdiction with the BWC attorney.

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

3.     If the investigation does not clearly reveal the correct employer and the claims appear to be duplicates in other respects, BWC staff shall staff the claim with the BWC attorney for further direction.

 

F.     Combining and Decombining Claims

1.     BWC staff shall combine verified duplicate claims or decombine claims in the claims management system pursuant to the instructions in the CoreSuite Training manual and/or the “Duplicate claims/duplicate customer” CoreSuite job aid available on the Duplicate Claims policy page on COR.

2.     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, then the claims shall be combined into the claim in which compensation has or is being paid;

b.     The IC has issued an order outlining how BWC 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 services staff shall select the claim that has the most compensation paid as the surviving claim.

ii.      Claims services 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.

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

4.     Claims services staff shall decombine claims when either of the following occurs:

a.     The IC orders it; or

b.     Claims services staff combines claims in error. In this case, a BWC order is not required.

 

G.    Overpaid Compensation and Medical Bills

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

2.     If claims services staff identifies an overpayment of medical bills because of claim duplication, claims services staff shall follow the procedure 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 of the possible duplicate claims prior to addressing the combining of 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 services staff will combine the claims.

One Claim in Accepted Status and one in Pending Status

Yes

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

One Claim in Denied Status and one in Pending or Accept/Appeal Status

No

If the BWC denied the claim due to lack of medical evidence (as opposed to insufficient medical evidence) and there is now medical evidence for the BWC/IC to consider, an IW’s representative can file the additional evidence and ask the BWC/IC to reconsider the allowance based on the new evidence. Reconsideration does not apply if BWC denied the claim on the merits (medical review/ not in course and scope, etc). In that case, the IW must file a motion requesting continuing jurisdiction.

One Claim in Accepted Status and one in Denied Status

No

Staff with a BWC attorney for continuing jurisdiction.

Two Accepted Claims

Yes

Claims services 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 a BWC attorney for continuing jurisdiction.

One Claim in Accept/Appeal Status and one in Deny/Appeal Status

Yes

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

One Claim in Accepted Status and one in either Accept/Appeal or Deny/Appeal Status

Yes

If no appeals are filed and if the accident and time of injury are the same, claims services 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 in Dismissed Status and one in Pending Status

Yes

Contact the 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 in Dismissed Status and one in Accepted or Denied Status

Yes

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

One Claim in Dismissed Status and one in either Accept/Appeal or Deny/Appeal Status

Yes

If no appeals are filed and if the accident and time of injury are the same, claims services 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 expiration of the appeal period, the dismissed claim will be combined into the determined claim provided there are no appeals.

One Claim in Hearing Status and one in one of the other statuses

No

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