How Can a Sedgwick Employee File a Grievance Again the Ada Claims Department

Brusk takes on emerging manufacture issues – government compliance updates, new paid parental exit laws and new Medicare set-asides

The alphabet soup of government compliance

CONTRIBUTORS

DARRELL Chocolate-brown
Principal Claims Officer, Sedgwick

BRYON BASS
SVP, Inability and Absenteeism Management, Sedgwick

There are many recent industry-related changes and others on the horizon that could have a significant touch on employer programs. Some of these legislative updates and rule changes occurred during 2016 and will become effective soon; others were appear more recently and are still pending last approval.

WORKERS' Compensation

ISO ClaimSearch enhancement
As of February 1, 2017, the per-claimant submission rate for an index bureau study increased from $9.20 to $9.50 to support production development and enhancements. All workers' compensation indexes search the unabridged ISO database regardless of the age of the claim.

The ISO ClaimSearch index system is a valuable investigation tool that satisfies multiple statutory and regulatory requirements such as:

• Individual country mandatory and voluntary child support requirements – When an alphabetize is submitted, ISO ClaimSearch searches the Child Support Lien Network and the federal Office of Child Back up Enforcement databases. If our claim matches a record in the database, the state child support enforcement bureau will receive the match information. If the agency decides to place a lien on a claim, the agency will notify your company directly.
• Medicaid reporting – The ISO ClaimSearch Medicaid Reporting Service keeps u.s. in compliance with the Medicaid reporting and verification requirements in Rhode Island.
• Auto line of business – Reporting to the ISO ClaimSearch system satisfies the automobile reporting requirements for theft and relieve claims in six states and for Regulation 64 of New York. It also fulfills reporting requirements of automobile insurance and auto accident reporting in New Jersey and Pennsylvania.

An initial index search using the ISO ClaimSearch database service provides a historical look back on claim history, as well as the following defined menstruum of updates:

• Prey – One twelvemonth of continuous updates; claims are searched for a 5-yr period from appointment received
• Property – threescore days of continuous updates
• Vehicle – 30 days of continuous updates; claims with VINs are searched back to 1981 when they became 17 digits

New WCIRB reporting requirement for first aid claims
On January i, 2017, all insured employers within the state of California were required to brainstorm reporting all claims for which medical treatment costs are incurred. The Workers' Compensation Rating Bureau of California (WCIRB) amended the California Workers' Bounty Uniform Statistical Reporting Plan-1995 clarifying the requirement to report get-go assistance and pocket-size medical simply claims regardless of whether the cost of medical treatment is paid by an employer or the insurer. The WCIRB Bulletin No. 2016-25 summarizes these changes. To comply, insured employers paying medical costs for first aid medical handling must written report those claims and the related medical costs to Sedgwick. We will create a medical only claim file and study it to the insurance carrier. Physicians must transport copies of the Physician's Offset Report of Occupational Injury or Illness to the insurance carrier or employer within 5 days of the initial exam. The insurer or employer must submit the physician'southward written report with the Department of Industrial Relations within five days of receipt. Any employer or physician who fails to comply may be assessed a penalty.

ERISA and FMLA compliance
The U.S. Section of Labor (DOL) continues to increase their compliance reviews on Family and Medical Leave Act (FMLA) and Employee Retirement Income Security Act (ERISA) plans. The DOL can perform compliance reviews for the FMLA and the ERISA without a formal complaint or crusade. Sedgwick monitors legislative changes related to the FMLA, ERISA and other industry programs; and we proceed to provide data on major changes that impact our clients. For DOL updates, please see the DOL website .

OSHA reporting requirements
The Occupational Safety and Health Administration (OSHA) introduced a new requirement for U.S. employers to submit records electronically. The final dominion , published on May 12, 2016, includes the following reporting deadlines for employers:

2016 reporting year

• Employers that take establishments with a headcount of xx–249 employees and/or a headcount of at to the lowest degree 250 employees must submit their 300A reports by July ane, 2017

2017 reporting year

• Employers that take establishments with a headcount of at least 250 employees must submit their OSHA 300A along with certain elements of their OSHA 300 and 301 by July i, 2018
• Employers that accept establishments with a headcount of 20–249 employees must submit their 300A by July 1, 2018

2018 reporting twelvemonth

• Employers that have establishments with a headcount of at least 250 employees must submit their OSHA 300A along with certain elements of their OSHA 300 and 301 past March 2, 2019
• Employers that have establishments with a headcount of 20–249 employees must submit their OSHA 300A by March 2, 2019

Sedgwick volition exist able to submit reports on behalf of customers that utilize our OSHA services to run into this electronic reporting requirement. Withal, employers will ultimately be responsible for the completeness and accurateness of the information. For more than information on the format of the files to be prepared for submission, please contact your client services manager.

DISABILITY AND LEAVE

EEOC compliance
Recently, the U.S. Equal Employment Opportunity Commission (EEOC) issued a Strategic Enforcement Plan (SEP) for Fiscal Years 2017–2021 . For compliance purposes, the EEOC narrows its focus on the Americans with Disabilities Act (ADA) to issues related to qualification standards and inflexible leave policies that discriminate against individuals with disabilities. Boosted areas include all-around pregnancy-related limitations under the ADA and the Pregnancy Discrimination Human activity.

PROPERTY

Florida Supreme Courtroom determination impacts holding loss claims
A recent stance of the Florida Supreme Court on property insurance coverage dramatically impacted future cases related to coverages in circumstances where several causes upshot in property damages, and at least one or more is covered by insurance and others are specifically excluded or not covered. With the Sebo Florida Supreme Courtroom decision on December 1, 2016, Florida has adopted the "concurrent cause" doctrine when analyzing belongings insurance coverages and losses. If at to the lowest degree one of several independent causes constitute, in part, a concurrent cause of the overall loss, and that cause is covered by insurance, the entire claim should be covered. In the Sebo decision, the combination of air current-driven rain during a hurricane (which was covered nether the insurance policy) and lacking construction or workmanship on an $8 one thousand thousand mansion on the Florida declension (which was specifically excluded nether the policy) caused the total loss of the entire residence. The insurance company had denied coverage based on the defective workmanship exclusion. The visitor lost the case every bit a result of the Florida Supreme Courtroom's ruling.

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New paid get out laws introduced

BY SHARON ANDRUS
Director, National Technical Compliance, Disability Administration, Sedgwick

Paid family unit get out and paid parental leave are currently key topics for employers as they await to aggrandize benefits for their employees. Recently, San Francisco introduced a paid parental leave ordinance and New York appear a new paid family leave benefits police. Below is a brief summary on each of these.

San Francisco
The San Francisco paid parental leave ordinance (SF PPLO) impacts all San Francisco-based employers with more than 50 employees nationwide. For example, a company with 1,000 employees across the U.S. and 25 working in San Francisco would be required to provide benefits to their San Francisco squad every bit of January 1, 2017. Employers with 35 or more employees are required to comply beginning July 1, 2017 and employers with 20 or more than employees on January 1, 2018.

The police force requires employers to provide six weeks of supplemental paid parental go out to employees working in San Francisco for the birth of a child, and the placement of a kid for adoption or foster intendance. Employers must provide up to 45% of supplemental pay and then that, when combined with California paid family go out (CA PFL) benefits, employees will receive up to 100% of their normal gross weekly wages (subject to CA PFL maximums). The get out must be completed in the first 12 months after the nascency or placement of the child.

Eligibility requirements:

• Employee commenced employment with the covered employer at least 180 days before the start of the go out
• The employee performs at least eight hours per week of work in San Francisco for the employer
• At least 40% of the employee's total weekly hours for that employer are in San Francisco
• Employee must exist eligible for and receiving CA PFL for baby bonding

One way that employers can comply with (or be exempt from) the SF PPLO is by providing equivalent benefits under their existing paid parental leave policy. Employers should review their policy to exist certain it satisfies the following minimum requirements of the SF PPLO:

• Applies to all employees regardless of (for example):

– Full-time/part-fourth dimension status
– Salaried/hourly
– Matrimony/not-union
– Exempt/not-exempt

• Provides 100% of pay up to 6 weeks for bonding with a newborn, an adopted kid or a foster child
• Eligibility for leave cannot exist greater than 180 days of employment prior to the showtime of the go out
• Applies every bit to mothers and fathers
• Applies every bit to primary and secondary caregivers

Another mode employers can comply with the SF PPLO is past handling it under their California Voluntary Disability/Paid Family leave plan.

The following items would need to exist taken into consideration before determining if this is a feasible solution:

• Perform a feasibility study if the voluntary plan is funded with employee contributions
• Amend the CA voluntary plan to include a separate class for SF employees that would pay 100% benefit
• Provide written find to all employees of plan modify; including the option to opt out of voluntary plan
• File revised plan document and employee notice to EDD for blessing

If employers are not able to embrace the SF PPLO obligation under their existing paid parental leave policy or CA voluntary plan, then they must create a separate policy and procedure to comply with the ordinance.

For more than information on benefits, eligibility, supplemental payments and intermittent go out, along with frequently asked questions, please see the Paid Parental Leave Ordinance on the City and Canton of San Francisco website.

The do good details and compliance requirements of new paid get out laws tin be complex. If your company has questions or concerns related to the new San Francisco ordinance, please contact your Sedgwick client services director.

New York
On Feb 22, 2017, regulations for the New York Paid Family unit Leave Benefits Law (NY PFLBL) were released. Employers, unions, carriers and third party claims administrators can provide feedback and enquire questions during a 45-day period earlier the regulations are finalized.

The NY PFLBL will become constructive on January 1, 2018 and employees will receive benefits to:

• Care for the serious wellness condition of a family member, including a spouse or domestic partner, child (biological, adopted, foster or in loco parentis), parent, grandparent and grandchild
• Bond with a new child during the showtime 12 months afterward birth, adoption or foster care placement
• Treat a spouse, parent or child as a effect of armed forces exigency

The weekly benefit is scheduled to gradually increase in subsequent years and is based on a percentage of New York's statewide average weekly wage (AWW). Below are the percentages for the weekly benefit:

• January 1, 2018: l% of weekly wage for 8 weeks
• January 1, 2019: 50% of weekly wage for ten weeks
• January i, 2020: 60% of weekly wage for 10 weeks
• January i, 2021: 67% of weekly wage for 12 weeks

The benefits are designed to be fully funded by employee contributions, which volition be deducted from the employees' pay. Full-fourth dimension employees are eligible after 26 sequent weeks of covered New York employment and part-time employees are eligible after 175 days of covered New York employment. When an employee returns to work, they must be restored to the same or a comparable position that they had prior to taking PFLBL.

Sedgwick is prepared to back up customers for whom we administer statutory disability claims in New York to assistance them comply with the PFLBL. Awaiting the release of the final regulations, nosotros recommend that employers:

• Evaluate their employee demographics to decide whether any employees meet the eligibility criteria
• Engage with a benefits consultant and/or legal counsel for guidance on policy/plan development including updating employee handbooks or leave material to include the PFLBL
• Prepare their payroll functions to add together another deduction for the PFLBL
• Gear up to maintain the employees' existing health coverage for the duration of the PFLBL

For additional information on eligibility and benefits, delight see New York's paid family unit exit plan on the New York State website.

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It is happening: LMSAs (and NFMSAs) are about here

BY MICHAEL R. MERLINO Ii, ESQ.
SVP, Medicare Compliance, Sedgwick

The Centers for Medicare & Medicaid Services (CMS) recently released a communication to providers, physicians and suppliers announcing that liability Medicare ready-bated arrangements (LMSAs) and no-fault Medicare gear up-aside arrangements (NFMSAs) will be implemented on October 2, 2017.

The commodity did not contain whatever particulars well-nigh how the new set-asides are going to work, only noting that new processes and procedures would be forthcoming. Until more details become available, stakeholders are left wondering how the set-asides will affect their liability and no-fault claims. Here are some primary questions and concerns to consider:

• How are we going to address liability cases with grave injuries, just low liability? Will CMS run across these cases as zero LMSA situations because clearly there was no future medical taken into consideration for the settlement?
• How is CMS going to toll MSAs? Is it going to assume that the parties take accepted the responsibility for lifetime medical expense, as in workers' compensation? Will CMS recognize there is zip in the law that indicates that the defendant is responsible for lifetime medical expenses when litigating or settling a liability example?
• What medical records is CMS going to require? Unlike workers' bounty, there are no payment histories in liability, then how is CMS going to verify what drugs and treatments are related to the liability case?
• How volition CMS determine the relevant body parts in a liability setting? In workers' compensation, there are forms and processes for only litigating a relatively narrow listing of body parts. In liability, we accept broad injury allegations coupled with medical records that are alleged to relate to the incident. Only how are these medical records going to exist interpreted to determine the reality from the plaintiff's claims? Will CMS take deposition testimony, expert witness testimony, interrogatories, etc. to disprove some of the medical treatment?

Our list of questions will abound as Sedgwick continues to evaluate the requirements and create best practices to drive optimal outcomes for customers and consumers.

We will monitor the state of affairs and work with our customers, carriers and manufacture partners to provide additional analysis and revise our best practices. Our team will also scout CMS for boosted details and continue to share data and recommendations in this area.

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Source: https://edge.sedgwick.com/issue_007/edging-up/

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