DWC’s Audits and Investigations (A&I) conducts more than 50 compliance audits per year of workers’ compensation system participants and prepares confirmed complaints for potential enforcement action. 59 Audits done in fiscal year 2022 (through Aug. 31, 2022).
Compliance Audit Goals for the fiscal year ending August 31, 2023:
- Timely and accurate benefit delivery
- Timely medical reimbursement
- Timely and accurate electronic data reporting to the DWC
Audit Scope & Methodology
Accuracy of Lifetime Income/Death Benefit Payments and Claims Data
The sample data from claims for injuries between Sept. 1, 2005, and April 30, 2022.
Timely Processing of Medical Bills, Timely Reporting Medical Bill Data, and Accuracy of Medical Bill Data
The sample data from billing lines submitted to DWC during the period of Sept. 1, 2022, through Nov. 30, 2022, or Dec. 1, 2022, through Feb. 28, 2023, depending on the date of the audit initiation.
Timely Paying Initial Temporary Income Benefits (TIB), Timely Reporting Initial Payment Data, and Accuracy of Initial Payment Data
The audit samples will consist of randomly selected records drawn from DWC’s database of claim information insurance carriers submit to DWC. The sample data was drawn from claims where an insurance carrier issued an initial TIB payment during the period of either July 1, 2022, through Sept. 30, 2022, or Oct. 1, 2022, through Dec. 31, 2022, depending on the date of the audit initiation.
2023 Medical Quality Review Panel (MQRP) Annual Audit
- DWC will conduct one audit to evaluate the appropriateness of a healthcare provider’s decision-making and recordkeeping for prescribing gabapentin with opioids.
- MQRP members will assist with the Health Care Provider Performance Based Oversight 2023 Assessment to evaluate documentation of why an injured employee is prevented from returning to work as reported on the DWC Form-073, Work Status Report.