Presentation on Where EDI Meets the Hearing Docket - PowerPoint Presentation

Presentation on Where EDI Meets the Hearing DocketChristen Burkholder, Deputy CommissionerStephanie Sweeney, EDI QA ManagerRyan Duke, EDI QA Assistant ManagerVirginia Workers’ Compensation Commission

Agenda Introductions What is EDI Updates to the dataDenial for no coverageMultiple named employers and carriers Penalties/Show Cause Q&A 2 [FOOTER TEXT]

Introductions & Introductory Questions Introductions Introductory questions Additional topics to discuss if time permits?3[FOOTER TEXT]

What is EDI?

What is EDI? Electronic Data Interchange The electronic exchange of data from one entity to another .Specific to workers’ compensation: the electronic exchange of workers’ compensation claims data from a Claims Administrator to the JurisdictionAccident InformationParty InformationDisability PeriodsPayment information – both medical and indemnity Universal reporting standard which is a benefit to a Claims Administrator A Claims Administrator can be the Insurance Carrier, Third Party Administrator or the Self-Insured, Self-Administered Employer 5 [FOOTER TEXT]

What is EDI used for in Virginia? Populate a Jurisdiction’s claims processing system Generate Notices Better Data QualityMonitoring PaymentsTimely Reporting6[FOOTER TEXT]

Virginia EDI Implemented the IAIABC Claims Release 3 Standard Go-live date was October 1, 2008 with a phased implementation Full compliance by July 1, 2009Va. Code § 65.2-900(A) requires with in 10 days, “a report of the injury or death shall be made and transmitted to the Commission by the employer, its representative or, in the case of an insured employer, its insurance carrier, in accordance with the regulations adopted by the commission…” 16 VAC 30-91-20 provides “all claims reports must be filed electronically .” Specifically calls out both FROIs and SROIs in accordance with our Implementation Guide 16 VAC 30-91-10 defines “filed electronically” to mean filed with the Commission through the Electronic Data Interchange (EDI) or through the Internet portal established by the Commission for submission of reports, pursuant to the requirements set forth in the implementation guide. 7 [FOOTER TEXT]

Virginia EDI – Required Reports FROIs and SROIs Va. Code § 65.2-902(A) provides for a penalty of not more than $500 for each failure to file a required report. The statute also provides for a penalty of not less than $500 and not more than $5,000 if the Commission determines a failure was willful .Bailey v. Northampton Middle School, JCN VA02000024907 (June 27, 2017)Failure to file Initial FROI$250 fines assessed Show Cause Did not appear Opinion assesse d (CDC Opinion, Request for Review Withdrawn Aug. 6, 2018): $500 penalty for willful failure to timely file $100 fine for failure to appear at Show Cause hearing $10 per day penalty for non-compliance until transaction is filed 8 [FOOTER TEXT]

Statute of Limitations A claim must name the correct employer in order to be legally effective and toll the statute of limitations.   Garcia v. Mantech Int’l Corp., 2 Va. App. 749, 752, 347 S.E.2d 548, 550 (1986).Naming the incorrect employer does not preserve the statute of limitations, regardless of whether the employer had notice of the accident.  Ramirez v. CSM Contractor, Inc., JCN VA02000023635 (Oct. 20, 2017)(citing Garcia v. Mantech Int'l Corp., 2 Va. App. 749, 755, 347 S.E.2d 548, 551 (1986)). It is the carrier’s EDI transactions, and not the information submitted by the claimant or the attorney filing the claim, that will determine: (1) who is the employer that appears in the style of the case; and (2) who are the parties that will receive the Commission’s notices regarding the claim.9 [FOOTER TEXT]

Updates to the data

Data Ownership Claim Administrators own the data Decision made in 2008 when going live with EDI VWC cannot fix incorrect data submitted via EDIFROI 02 Change TransactionFirst request gives 14 daysPre-Contempt gives additional 10 daysPhone call/email made to business contactFine issued Show Cause Mosley v. 21 Enterprise Leasing Co. of Norfolk, JCN VA00001067930 (Oct. 26, 2017) Failure to update employer’s address $250 fines assessed Show Cause Did not appear Opinion assessed: $500 penalty for willful failure to timely file $100 fine for failure to appear at Show Cause hearing $10 per day penalty for non-compliance until transaction is filed Review Opinion Affirmed 11 [FOOTER TEXT]

Data Updates – Requested v. Non-Requested Requested Approval received from D.C. when case is on the docket – Expected Change Must be filed timely. If not:Delay the hearing and other significant Commission processesDelay in the issuance of the opinion or orderCase could be heard with incorrect informationOrders issued to incorrect partiesOther notifications will also be generated to incorrect parties Potential Fine Non-requested Data may be incorrect Delay the hearing and other significant Commission processes Delay in the issuance of the opinion or order Case could be heard with incorrect information Orders issued to incorrect parties Other notifications will also be generated to incorrect parties Correct party may not receive our notifications or know any action is taking place Potential request to revert data back to previous information Potential fine 12 [FOOTER TEXT]

Denials

No Coverage Should the claim Admin file EDI? NO Send a letter to the EDI QA department if you have received a request from the VWC to file EDIWhat happens if you do file EDI?VWC can not change the parties so the parties listed on the JCN will remainYou will continue to receive notices When a decision is made regarding the correct parties, what happens? If EDI has not been filed, an update is made to the JCN to reflect the correct parties A request for FROI 00 is sent to the responsible party If EDI has been filed, VWC can not change the parties of if the incorrect party is named A Request for FROI AQ is sent to the responsible party The incorrect parties will remain listed on the JCN until the requested transaction is received. 14 [FOOTER TEXT]

Longshore / All other Longshore Pre 7/1/2012 YESFROI 04 Denial transactionCode 3D for no jurisdictionLongshore notice will be sent to the partiesPost 7/1/2012NOEffective 7/1/2012, Virginia no longer has concurrent jurisdiction with Longshore Subdivision 2N of the definition of “Employee” in VA. Code § 65.2-101 All Other Should the claim Admin file EDI? YES A notice of Denial will be sent to the parties indicating your position on the claim 15 [FOOTER TEXT]

Multiple Named Employersa nd Carriers

Notice to Multiple Employers Notice to both employers is required to avoid any due process violation.  Each employer or statutory employer is entitled to notice enabling it to make a defense to the claim being asserted.   Race Fork Coal Co. v. Turner, 237 Va. 639, 644, 379 S.E.2d 341, 344 (1989).The interest of statutory employers and direct employers diverge, and the statutory employers are not in privity with the direct employers, therefore notice of the claim to the statutory employer is constitutionally required.  Race Fork Coal Co. v. Turner, 237 Va. 639, 643, 379 S.E.2d 341, 343 (1989).Va. Code § 65.2-600(A) addresses the notice requirements for statutory employers.   If notice of accident is not given to any statutory employer, such statutory employer may be held responsible for initial and additional awards of compensation rendered by the Commission if ( i ) he shall have had at least sixty days’ notice of the hearing to ascertain compensability of the accident, and (ii) the statutory employer was not prejudiced by lack of notice of the accident. 17 [FOOTER TEXT]

EDI Filings Before Decision Who should file? NO ONE Wait until a decision is made by a D.C. indicating who is the responsible party(s) Impacts of wrong EDI filerThe filer will be listed in the JCN as the responsible partyNo changes can/will be made until a decision is madeMay require additional EDI submissions once a decision has been made May result in penalties and show cause hearing Will require any other data updates (DOI, claimant info, etc.) to be made by the filer May result in penalties and show cause hearing What if both parties file EDI? Two or more JCNs will exist Consolidation may be required Additional EDI submissions once a decision has been made May result in penalties and show cause hearing Cause confusion with agency personnel when placing paper submissions in file or when D.C. is conducting hearing 18 [FOOTER TEXT]

EDI Filings After Decision One party ordered to pay If more than one JCN exists, consolidation will be performed Requests for EDI will be sentInitial FROI if neededSROI to report paymentCancellation transaction if more than one JCN exists Two or more parties ordered to payWill require 2 or more JCNs One for each payer Allow each payer to submit EDI 19 [FOOTER TEXT]

Fines/Penalties and Show Cause

§ 65.2-902 Failure to Make Required Reports; Civil Penalties “A. Any employer, insurance carrier, self-insurer, group self-insurance association, or third party administrator who fails to make any report required by the Commission pursuant to this title shall be assessed a civil penalty of not more than $500 for each failure. If the Commission determines that any such failure is willful, it shall assess a civil penalty of not less than $500 and not more than $5,000. The civil penalty herein provided may be assessed by the Commission in an open hearing with the right of review and appeal as in other cases.” 21[FOOTER TEXT]

EDI Areas Resulting in Fines/Penalties Failure to File Initial FROI Failure to File Requested Transaction(s) This includes requests issued by the Commission to change data within the claim, such as the claimant’s name, date of injury, etc…Also included, is transactions submitted incorrectly which require re-submission, or the submission of other transactions to correctFailure to File SROI This is mainly composed of claims where an Award issuing payment is issued but no SROI reporting payment is submitted22 [FOOTER TEXT]

Fine/Penalty Process Initial request for EDI is sent 30 days Pre-contempt Order is sent14 daysCall/email made to business contact for Claim Administrator7 daysReferred to EDI QA Assistant Manager for final reviewFine/Penalty Issued$250 for each occurrence 23 [FOOTER TEXT]

After Fine/Penalty Issued If transaction is not filed, referred to Judicial Issue a Show Cause Warning Gives 14 days to file before scheduled for a Show Cause HearingIssue a Show Cause Order and Notice of HearingJCN is reviewed the day prior to hearing to see if transaction is filedIf yes, Show Cause is quashed immediatelyIf no, proceed with hearingOpinion Issued Could result in additional fine for willful Transaction is still due Appeal Written request to appeal Fine/Penalty Referred to Judicial Docket OTR Hearing is scheduled Schedule for written statements is issued Opinion Issued Could result in additional fine for willful Transaction is still due May be appealed to the full Commission 24 [FOOTER TEXT]

Conclusion

Commission Concerns that Impact Hearings Duplicate JCNs Paper filing by claimant or his/her counsel JCN AssignedEDI filing made by Claim AdministratorIf JCN not used from paper filed AND not caught by our duplicate checkJCN AssignedNew CFB sent to the claimant2 or more JCNs assignedConsolidation More required EDI transactions Possible Fines/Penalties Date of Injury on Occupational Disease Cases Date of Injury = Date of Communication Coverage based on Date of Last Exposure EDI issues Claim Admin’s system can’t send with correct DOI because it is outside their policy period Late Filings Discussed previously throughout the presentation – impacts several processes within the Commission 26 [FOOTER TEXT]

Need help? Contact the EDI Quality Assurance Department Edi.support@workcomp.Virginia.gov Responses within 24 hours 877-664-2544Ask for EDI QACall Ryan or Stephanie directly804-588-3799804-205-3104 27 [FOOTER TEXT]

Questions 28 [FOOTER TEXT]

Additional Information Contact the Virginia Workers’ Compensation Commission 333 E. Franklin St., Richmond, VA 23219 1-877-664-2566 www.workcomp.virginia.gov EDI Specific Inquiries: edi.support@workcomp.virginia.gov 29 [FOOTER TEXT]