"A" = Actual Control "P" = Proposed Control
| CONTROLS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| THREATS | C-01 Experienced personnel. | C-02 Written policies and procedures. | C-03 Monthly staff meetings. | C-04 Training provided by outside attorneys certified by the Workers' Compensation Appeals Board. | C-05 Training provided in-house: meetings, seminars, insurance periodicals, and classes. | C-06 Supervisors monitor "stages" of claims, i.e., penalties, denials, and delays. | C-07 Supervisors review for proper documentation and approve all files for closure. | C-08 Bills to be paid are reviewed at three personnel levels - adjusters, clerks, & accounting, and by the David System. | C-09 Adjusters request supervisors to review and discuss specific claims files. | C-10 The claims supervisors and Workers' Compensation Manager meet on a daily basis. | C-11 Outside attorneys can be called and they answer questions promptly. | C-12 Good communication and good relationship among personnel. | C-13 No employee turnover for the last two years and very low turnover rate before that. | C-14 Random and targeted audits by the Office of Benefits & Enforcement (OBAE). | C-15 Random & targeted audits by the Self-insured plans division. | C-16 Workers' Compensation Appeals Board (WCAB) oversees adherence to State policies and procedures. | C-17 Employees can obtain legal representation. | C-18 "Internal policing" - complaints from co-workers. | C-19 "External policing" - complaints from employees with claims. | C-20 Performance appraisals evaluate adherence to policies & procedures. | C-21 State-mandated penalties are self-assessed. | C-22 Monthly reports monitor performance of adjusters. | C-23 Unsatisfactory performance trends result in problem-solving session for better caseload management. | C-24 The State-required funding levels to pay current and future liabilities. | C-25 The actuarial studies determine proper levels of funding. | C-26 The City provides historical claims information to the actuary. | C-27 The City provides financial assumptions used by the actuary. | C-28 The Risk Manager must evaluate and report on the possibility of purchasing excess insurance. | C-29 GASB 10 requires public entities to report all current and potential liabilities. | C-30 The David System produces management summaries on the cost of claims. | C-31 A claims management database (David System) was installed. | C-32 Four major "data clean-ups" have occurred. | C-33 Clerical assistants have special training sessions on proper data entry and update information as needed. | C-34 Monthly management reports would reveal any problems with database information. | C-35 City Departments inform Workers' Compensation of inaccuracies. | C-36 Workers' Compensation informs departments of database inaccuracies. | C-37 Program personnel performed random testing of data before conversion to David System was accepted. | C-38 Payments are balanced to the source documents as well as to the database information. | C-39 The City uses five major categories for proper classification of employees. | C-40 Department job classification codes are used. | C-41 Department job classification codes are cross-referenced to one of the five categories. | C-42 Inventory Control Reports are run monthly for each adjuster. | C-43 Penalty Reports are run monthly for each adjuster. | C-44 Workers' Compensation Manager reviews the Check Log for possible inefficiencies in caseload management. | C-45 Caseloads are reviewed on a monthly basis and are reassigned when imbalances occur. | C-46 The David System checks for duplicate payments. | C-47 The adjusters review the amounts of the medical bills. | C-48 The clerks recalculate amounts of the medicals bills. | C-49 Meetings are held with other departments regarding claims management. | C-50 Adjusters work with physicians and City departments to return employees to work. | C-51 Adjusters review medical reports. | C-52 Adjusters concentrate on the abusers. | C-53 An investigator is assigned in cases of suspected abuse. | C-54 A Diary system is used to manage claims. | C-55 File closure to be done before the end of the month. | C-56 A Reserve Computation Worksheet is used to calculate reserves. | C-57 There are levels of authority for establishing and/or increasing the amount of reserves. | C-58 Additional sign-off is required for reserves above certain levels. | C-59 Reserves over $100,000 can only be established by the program manager. | C-60 The David System automatically assigns a reserve of $2,000 to Medical-only claims. | C-61 "Negative Reserves" reports are run monthly. | C-62 The David System will not allow additional payments if a claim's reserves go negative. | C-63 Senior Account Clerk informs the adjuster of negative reserves on a claim. | C-64 Adjusters must prepare a new Reserve Computation Worksheet after changing the level of reserves on a claim. | C-65 Reserves are always examined when adjusters and their supervisors review a claim. | C-66 Files contain documentation when there has been a major change in reserve levels. | C-67 Auto-payments must be authorized by adjusters. | C-68 All indemnity payments are processed by adjuster. | C-69 Medical-only payments may be processed by clerks but are reviewed by supervisors at closure. | C-70 Medical payments are paid according to a fee schedule established by the State. | C-71 Adjusters contact employees to verify medical or medical/legal visit & treatment on claims they deem questionable. | C-72 There are levels of authority for payment amounts. | C-73 Risk Mgr, Workers' Comp Mgr, & Safety Officer conducted Workers' Compensation information session for Senior Mgmt. | C-74 The Safety Officer has written a safety manual. | C-75 The Risk Manager is developing a Supplemental Claims Questionnaire. | C-76 Meetings with departments to discuss Workers' Compensation issues which may include loss prevention. | C-77 A Claims Task Force is planning extensive safety education & training for supervisors throughout all departments. | C-78 The Workers' Compensation Manager receives and evaluates all DWC5020s for possible subrogation. | C-79 Senior Account Clerk receives the DWC5020 and develops the claim files for possible subrogation. | C-80 Traffic Collision Reports are used to assess collectibility. | C-81 Crime Reports are used to assess collectibility. | C-82 Department Vehicle Damage Reports are used to assess collectibility. | C-83 Telephone calls from City employees aid in assessing collectibility. | C-84 Invoices are prepared and sent to Treasury for attempted collection. | C-85 Treasury attempts to collect on invoices less than $3K and when parties are not legally represented. | C-86 City Attorney attempts to collect on invoices over $3K and/or when parties are legally represented. | C-87 The State provides a checklist of criteria for fraudulent claims. | C-88 City will submit questionable claims which meet criteria of a fraudulent claim to State Fraudulent Claims Bureau. | C-89 Adjusters receive anonymous letters and phone calls. | C-90 A list of Fraud Indicators has been developed for Workers' Compensation use. | C-91 A list of Fraud Indicators has been developed for Police Department use. |
| T-01 External (State) policies and procedures are not followed. | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-02 Internal policies and procedures are not followed. | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-03 System benefits are not delivered within the timelines set by the State. | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-04 The City cannot pay current and/or future claims liabilities. | A | A | A | A | A | A | A | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-05 Claims information in the database is inaccurate. | A | A | A | A | A | A | A | A | A | A | A | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-06 Employees are misclassified by category. | A | A | A | A | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-07 Claims adjusters are not efficient or effective in caseload management. | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-08 Employees do not return to work on a timely basis. | A | A | A | A | A | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-09 Claims are not closed on a timely basis. | A | A | A | A | A | A | A | A | A | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-10 Claims are over- or under-reserved. | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | A | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-11 Unauthorized payments on claims are made. | A | A | A | A | A | A | A | A | A | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-12 Loss prevention goals are non-existent. |