OAKLAND, Calif., July 20, 2022--(BUSINESS WIRE)--Proposals to cut the amount of time California workers’ compensation claims administrators have to investigate work-related injuries and determine employer liability may be easier said than done given existing statutory and regulatory time frames for the various steps within the process, many of which claims organizations do not control, according to a new analysis by the California Workers’ Compensation Institute (CWCI).
The length of a workers’ comp investigation varies depending on the type of injury reported, circumstances surrounding the injurious event, witness availability, the cooperation and availability of the parties involved, the number of issues and medical conditions asserted, and the availability of documentation. The CWCI study notes that reducing compensability determination time frames would make it hard to fully investigate claims, especially those that are litigated or denied. Currently under consideration by the California Legislature, SB 1127 would reduce the investigation period for claims where workers are given a presumption of compensability to 75 days from the employer notification of injury, while the investigation period for other claims would remain at 90 days. The CWCI analysis examines the underlying issues associated with this and other recent proposals to reduce claim investigation time frames and uses data from 459,195 non-COVID-19 claims and 17,135 COVID-19 claims to assess the impact of the proposals. Key findings include:
Accepted claims without litigation are the most frequent, least complex claims in the system. In 98.0 percent of these claims, compensability is determined within 90 days, while in 96.7 and 93.2 percent of these claims the decision is made within 60 and 30 days, respectively. When non-litigated and litigated non-COVID-19 claims are combined, more than 90 percent have a decision within 75 days.
Investigation periods are longer for litigated and denied claims and require significantly more time to gather reports and documentation from outside sources. For example, at 75 days, only 49.2 percent of litigated claims that are eventually denied have a compensability decision, strongly suggesting that under current rules and regulations, 75 days is an insufficient amount of time for claims administrators to obtain the medical and factual evidence required to make a compensability determination.
Under current law employers are already liable for up to $10,000 of medical treatment for a claimed injury during the investigation period, regardless of the ultimate compensability decision, so reducing that time frame would also reduce the amount of time that workers whose claims are eventually denied could receive that $10,000 worth of medical care.
Determining compensability is particularly challenging and time consuming for COVID-19 claims, especially those that are litigated. At the 45-day mark, 91.4 percent of accepted, non-litigated COVID-19 claims have a compensability decision, compared to 68.9 percent of the accepted COVID-19 claims that are litigated, a 22.5 percentage point difference. At 30 days, determinations have been reached on 85.5 percent of accepted, non-litigated COVID-19 claims, compared to 61.1 percent of the litigated COVID-19 claims that were accepted, a 24.4 percentage point differential.
The study’s findings show that reducing investigation timelines as proposed in prior and current legislation would create compensability determination thresholds that are unnecessary for accepted claims and unrealistic for litigated and denied claims. CWCI has released its analysis of the impact of reducing compensability determinations in an Impact Analysis report that is available for free to the public and can be found under the Research tab at www.cwci.org.
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