DCI Data Validation and Quality Issues

Transcription

1 DCI Data Validation and Quality Issues January 30 February 2, 2018 Palm Beach County Convention Center West Palm Beach, FL The Path to Data Excellence

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3 DCI Data Validation and Quality Issues Presented by: Kelly Blake and Chris Mercer To understand: Objectives Why we collect Detailed Claim Information (DCI) The aggregate data quality observation process Associated carrier outreach. 2 1

4 Agenda Carrier Outreach Process Element Data Quality PPD Benefit Type Distributions by State Attorney Indicator by State Indemnity Payment Comparison by Valuation Other Data Quality Outreach Claim Linking Recap 3 DCI Data Usage Legislative Pricing State Advisory Forums Research Studies 4 2

5 Carrier Outreach Process Carrier Outreach Process NCCI has a three step process to ensure that our data reporters provide quality DCI data. Defined aggregate data quality observations are reviewed quarterly By Element Data is compared to prior results and classified Data quality observations are sent to the carrier Trending with previous quarter results and review of prior carrier feedback 6 3

6 Aggregate Data Quality Observations What Are They? Observations that look for patterns or anomalies and identify carrier outliers from the industry For example, for closed claims with Temporary Total Disability paid, the number of days between Accident Date and Return to Work Date is < 4 days Include measures of DCI data elements and comparative analysis between the elements in the aggregate over at least six months 7 Aggregate Data Quality Observations Why Are They Necessary? All DCI data elements are required or conditionally required No optional elements DCI elements do not become optional because an edit does not require them Report all DCI elements as the claim develops Per claim values are reasonable but may be unreasonable in the aggregate 8 4

7 Return To Work (RTW) Date Indicates the most recent date the claimant returned to work Carriers sometimes capture Initial RTW and Current RTW dates impact to reporting Observations for Outreach: Closed claims percentage of missing Accident Date to Return to Work Date is less than four days 9 Return To Work (RTW) Date Why Isn t There an Edit to Reject Suspect Claims? Claims are edited individually Most claimants return to work after recovering Some claimants do not return to work 10 5

8 Necessary Analysis Before Outreach Trending current quarterly results with prior results: Results trending with industry norms Still trending different than the industry Results have improved or are no longer an outlier Review prior carrier feedback, if any, to see if an observation has been explained by the carrier. For example, an outlier is correct as reported 11 Other Data Quality Outreach Unexpected State Claim Volume Death and Permanent Total (PT) Claims DCI Claim Linking with Unit Data 12 6

9 DCI Resources Manuals Detailed Claim Information Reporting Guidebook Including Edit Matrices Statistical Plan Data Quality Guidebook Electronic Transmission User s Guide Communications Circulars and FYI Plus Series Web Articles 13 DCI Resources Online Tools DCI Data Collection (DDC) Data Manager Dashboard (DMD) Data Transfer via the Internet (DTVI) Webinars Detailed Claim Information Data Quality Services Pre Edit Service 14 7

10 Element Data Quality DCI Data Collection 16 8

11 DCI Data Collection 17 Data Quality Observations 18 9

12 Claim Details Screen Observations are ranked by carrier percentile group; for example: 0 Percentile to 10th Percentile 11th Percentile to 33rd Percentile 34th Percentile to 66th Percentile 67th Percentile to 89th Percentile 90th Percentile to 100th Percentile Generally, the outlier percentiles indicate possible data quality concerns 19 Percentiles Example Smallest Man inches Tallest Man 8 ft in. Extreme Outlier Outlier Normal Outlier Extreme Outlier 20 10

13 Claim Details 21 Medical Extinguishment Indicator 22 11

14 Medical Extinguishment Indicator Extract 23 Claimant Legal Amount 24 12

15 Claimant Legal Amount Extract 25 Vocational Rehabilitation Other 26 13

16 Vocational Rehabilitation Other 27 Low Occurrences 28 14

17 Permanent Partial Disability (PPD) Benefit Type Distributions by State Permanent Partial Disability (PPD) Benefit Type Distributions by State Periodic payments and lump sum payments by state Carrier percentage (ratio) of BT 03, BT 04, and BT 09; with BT 15 and BT 50 for select states Industry percentage (ratio) Median paid per Benefit Type; Carrier and Industry Differences between Carrier and Industry may indicate miscoding of carrier s internal payment codes to DCI defined Benefit Types 30 15

18 Benefit Type Observation On a per state basis, we look at: Ratio of periodic payments to lump sum payments Ratio of the various benefit type payments For example, state statutes have both scheduled and unscheduled PPD benefits, and a carrier has little to no claims with a schedule (Benefit Type 03) Overuse of Benefit Type 09, especially when the paid dollar amount is high and there are no scheduled or unscheduled benefits 31 Benefit Type Usage Allows NCCI to inform regulators of costs related to the impact of: Raising weekly benefit minimum or maximum rates Reforms to limit or expand the duration of a specific indemnity benefit; e.g., limit Temporary Total Disability to 104 weeks Adding, removing, or reforming a Benefit Type; e.g., adopting scheduled benefits or changing the number of weeks in the existing statute 32 16

19 PPD Distribution by State Delta % Carrier % of claims with the Benefit Type minus Industry % Claims Carrier s number of claims with the Benefit Type 33 PPD by Benefit Type Observations 34 17

20 PPD by Benefit Type Observations 35 PPD by Benefit Type Observations 36 18

21 Attorney Indicator by State Attorney Indicator by State Percentage of claims where the attorney flag is Y for claims open at 18 months and closed at the latest valuation Number of carrier claims can impact results Carrier percentage of Y Industry percentage of Y Carrier percentile ranking 38 19

22 Attorney Indicator Indicates whether the claimant has an attorney or authorized representative: Claimant attorney representation varies by state and claim status Observation for Outreach: Carrier percentage of Y compared with the industry on a per state basis, by open and closed claims 39 Attorney Indicator Observations 40 20

23 Attorney Indicator Extract Open at 18 months 41 Attorney Indicator Extract Closed at latest valuation 42 21

24 Per Claim Indemnity Payment Comparison by Valuation Per Claim Indemnity Payment Comparison by Valuation Comparison of paid amounts by Benefit Type for all valuations of a claim. For example, a 30 month valuation is compared with an 18 month valuation If the BT 05 paid at 30 months is less than the BT 05 paid at 18 months, the claim qualifies for display Claims are reviewed for periodic payments and periodic and lump sum payments combined 44 22

25 Payments on Subsequent Valuations Benefit Type payments reported on prior valuations shouldn t go away or be reduced, except in rare cases (e.g., a payment was voided and reclassified) If a Benefit Type was not correct on prior valuations, please correct those prior valuations If the claim settlements process erased those prior payments, retain the payments that were made prior to the final settlement Incorrect reporting impacts accuracy of development triangles 45 Valuation Observations 46 23

26 Valuation Observations 47 Valuation Observations 48 24

27 Claims With Reduction in Periodic Payments 49 Claims With Reductions in Combined Payments 50 25

28 Output Provided for Outreach 51 Other Data Quality Outreach 26

29 Observation Unexpected State Claim Volume Focused on individual states over an extended period of time (6 12 months) by open and closed claims Compare NCCI estimated claims that are based on Unit Statistical data with carrier supplied claims Review Sampling Ratios Review Unit Statistical Data Claim Pool 53 Outreach Unexpected State Claim Volume Common reasons for overreporting or underreporting: A subset of claims is missing from the pool Incorrect sampling ratio NCCI can provide: Open or closed unit statistical claims for a specific time period Compare the estimated Unit Statistical Pool provided by NCCI with the carrier s DCI Pool of claims 54 27

30 Death and Permanent Total (PT) Claims Compare Unit Statistical Death and PT claims with DCI claims. Claims with Injury Code 01 or 02 in Unit Statistical data but not in DCI data Verify logic for selection of Death and PT claims Common reasons for missing DCI claims: Only pulling 1st report level on the Unit Not using Injury Codes to identify claims for DCI 55 Output Provided for Outreach 56 28

31 Claim Linking DCI Claim Matching to Unit Data Allows NCCI to use elements from the Unit data in legislative pricing and research related to Indemnity benefits. Inconsistent format of Policy Number, Claim Number, or other Key Fields make this difficult

32 DCI Claim Matching to Unit Data As both DCI and Unit Statistical data don t have the same Key Fields, we use combinations of the following: Carrier Group Code Carrier Code Policy Number Policy Effective Date Claim Number Accident Date Jurisdiction State 59 Recap 30

33 Recap Carrier can monitor its own data by using the DCI Quality Observations feature in the DCI Data Collection (DDC) tool The feature compares a carrier s results to industry results Results can be for any period of time from one day to the entirety of the industry data Can extract claims for review 61 Recap Defined aggregate data quality observations are reviewed quarterly Carrier responds with an explanation or correction Data is compared to prior results and classified Data quality observations are sent to the carrier 62 31

34 Questions 63 32

35 Supplemental Information

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37 Presenter Biographies Christopher Mercer is currently the Data Steward for Detailed Claim Information and is responsible for the quality of this data. Chris has more than 20 years of experience in the insurance industry, predominantly in the workers compensation field. He has served as a manager in NCCI s Data Resources Division for more than 14 years, which includes time managing the Financial, Unit, Medical, and Detailed Information Data Validation Teams. Prior to that, he spent six years working for a workers compensation insurance carrier auditing and reporting data to NCCI, as well as being responsible for carrier compliance. Kelly Blake, CPCU, is the manager of NCCI s Medical Data and Detailed Claim Information Validation Teams and has worked in multiple roles at NCCI since Medical and DCI Data Validation encompass the collection, editing, storage, and validation of data associated with NCCI s Medical Data Call and DCI Data Call, including the development and maintenance of NCCI s data compliance programs. Kelly earned his bachelor s of Science in business management from the State University of New York at Geneseo. He is also designated as a Certified Property Casualty Underwriter (CPCU) and is a member of the CPCU Society.

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39 Detailed Claim Information Reporting Guidebook Part 10 DCI Quality Observations

40 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 1 A. OVERVIEW PART 10 DCI QUALITY OBSERVATIONS Part 10 of this guidebook is designed to provide details regarding each observation highlighted through the DCI Quality Observations feature in the DCI Data Collection tool. NCCI has a three-step process to ensure the quality of the DCI data reported: 1. Run defined aggregate data quality observations quarterly 2. Compare new results to previous quarter results 3. Send data quality observations to the carrier The observations pertain to DCI data that is used in research studies and legislative pricing. To enable customers to self-monitor the quality of DCI data reported, the DCI Quality Observations feature was added to the DCI Data Collection tool. The feature allows you to: View and monitor DCI data quality observation results. Provide a comparison with overall industry results as a point of reference to identify possible data quality issues. Download a list of claims supporting these observations. Download extracts of the specific claims that make up the carrier results for each observation. These extracts contain claim-specific details that relate to each specific observation. For more details on available DCI Quality Observations extracts, refer to Item D Claim Extracts in this part of this guidebook. The DCI data observations provide a review of DCI data elements based on an aggregation of carrier claims that meet specified criteria. The criteria may differ based on the observation being viewed. The criterion for each observation is provided in this part of this guidebook. Only data for applicable DCI states is included in the DCI Quality Observations feature. For a listing of applicable DCI states, refer to Applicable States in the General Rules section (Part 2) of this guidebook. For the complete DCI Data Dictionary, where all data element definitions and reporting requirements can be found, refer to Part 6 of this guidebook. B. GENERAL OBSERVATIONS General Observations are designed to provide aggregated statistics of a carrier group s reporting of specific critical DCI data elements or groups of related DCI data elements in comparison to the industry. The General Observations category includes: Claim Details Benefit Type Attorney Indicator Each observation provides results based on a predetermined time frame. Carriers have the ability to set the Start and End dates to query results based on either the Received Date or Reported to Insurer Date ranges. If no date is entered, then a Default date range will be used to generate results. The Default range is as follows: Default Start Date = Current Date less 364 days (365 days for leap years) Default End Date = Current Date 1. Claim Details Observations The Claim Details Observations show the percentage of a carrier group s DCI claims, compared to the industry percentage, for 18 key areas of concern. These observations are displayed in order based on percentile grouping. The order within each percentile grouping is alphabetized by Element Name and Observation Description. Observations with results that are significantly different from the industry results are prioritized at the top of the list. Each of the Claim Details Observations provides the following information: Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

41 PART 10 Page 2 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook Carrier % Percentage of claims reported with noted observation by carrier group (see chart below for calculations). Industry % Percentage of claims reported with noted observation for all carrier groups. Percentile Evaluation of the percentage of carrier data versus industry data segregated into five percentile groupings. The groupings are sorted per the table below, with the observations that are the furthest from the industry norm first. Any observations that fall below the individual observation threshold for claim volume will always be sorted to the bottom. Group 1 Carrier % is within the 0 10th percentiles. Observations in this range are well below the industry average and are worth reviewing and monitoring, except where noted in the Observation Notes. Percentile Groupings Group Evaluation Sort Order Group 2 Carrier % is within the 11th 33rd percentiles. Observations in this range are slightly below the industry average and may be worth reviewing, except where noted in the Observation Notes. Group 3 Carrier % is within the 34th 66th percentiles. Results within this group are considered to be the norm; therefore, you can assume that these results do not need to be reviewed. Group 4 Carrier % is within the 67th 89th percentiles. Observations in this range are slightly above the industry average and may be worth reviewing. Group 5 Carrier % is within the 90th 100th percentiles. Observations in this range are well above the industry average and are worth reviewing and monitoring. Claims Total number of claims by Received Date or Reported to Insurer Date and based on time frame requested with noted observation. Note: If the number of claims falls below a minimum threshold, then LCV or Low Claim Volume will display. These observations are deemed to have too few claims in the category to properly compare to the industry results. For on-screen sorting, these will be at the bottom, below Group 3 (industry average). The Claim Details Observations view provides 18 observations as follows: Element Name Accident State Observation Description Accident State Not Equal to Jurisdiction State Claims Observed All claims within the date range. Observation Notes Accident State is the state in which the accident occurred, while the Jurisdiction State is the state where workers compensation benefits are being applied or paid. For this observation, if you are in Group 2 (i.e., you have slightly fewer claims with the Accident State and Jurisdiction State not equal), you likely do not have an issue. If you are in Group 1, you may still not have an issue; but if the Carrier % is 0% (i.e., the Accident State is always the same as the Jurisdiction Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

42 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 3 Element Name Observation Description Claims Observed Observation Notes State), make sure that you are not defaulting the two elements to always be the same. Birth Year Derived Age < 15 or > 70 Years All claims within the date range. Birth Year Birth Year Missing All claims within the date range. If you are in Group 4 or 5, it is unusual for there to be a high percentage of submitted claims whose Accident State is not equal to the Jurisdiction State. Download the extract of these claims and review to determine whether these fields are being populated correctly. For this observation, if you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, it is unusual for a large percentage of individuals to be working under the age of 15 or over the age of 70. Download the extract of these claims and review to determine whether the claimants Birth Year is accurate. Be sure to look for instances where the Birth Year = Accident Year. For this observation, if you are in Group 1 or 2, you are likely reporting correctly. Claimant Gender Code Claimant Gender Code = 3 All claims within the date range. If you are in Group 4 or 5, it is unusual for a large percentage of claims to be missing the Birth Year. Download the extract of these claims and review to determine whether your system is capturing this element and that it is being populated correctly in the claim records. Claimant Gender Code 3 does not represent claimants whose gender is unknown; rather, Claimant Gender Code 3 is for claimants whose gender is not considered to be Male or Female. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, it is unusual for there to be a large percentage of individuals with the Gender of Other. Download the extract of these claims and review Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

43 PART 10 Page 4 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook Element Name Claimant Legal Paid Amount Observation Description Claims Observed Claimant Legal Paid Amount = 0 All claims within the date range. Observation Notes to determine whether these fields are being populated correctly. It is possible for the element to be $0 for a large portion if not 100% of the claims are reported IF the carrier group does not create a separate check for the claimant s attorney fees. If you write separate checks to the claimant s lawyers and are in Group 1 or 2, you are likely reporting correctly; however, if your result is 0%, review your data to ensure that you have been populating the fields correctly. Employer Legal Paid Amount Employer Legal Paid Amount = 0 All claims within the date range. If you are in Group 4 or 5, download the extract and sort by the Total Indemnity Incurred column (largest to smallest). Review the claims with the largest Indemnity Incurred amounts to see whether these claims should have had payments made for Claimant Legal expenses. If you are in Group 1 or 2, you are likely reporting correctly; however, if your result is 0%, review your data to ensure that you have been populating the fields correctly. Hire Year Hire Year to Accident Date Year > 4 Years All claims within the date range. Hire Year Hire Year = Accident Date Year All claims within the date range. If you are in Group 4 or 5, download the extract and sort by the Total Indemnity Incurred column (largest to smallest). Review the claims with the largest Indemnity Incurred amounts to see whether these claims should have had payments made for Employer Legal expenses. If the percentage of claims is significantly different from the industry norm, download the extract of these claims and review to ensure that the Hire Year is correct. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, download the extract of these claims and review to determine that you are not defaulting to Accident Year when you do not have the claimant s hire date. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

44 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 5 Element Name Impairment Percentage Impairment Percentage Observation Description Impairment Percentage = 1% or 2% Based on Part of Body Impairment Percentage = 1% or 2% Based on Whole Body Claims Observed Claims where (within the date range): Lump Sum Benefit Type or Periodic Benefit Type is 03, 04, 09, or 50 Corresponding Benefit Paid Amount is greater than zero dollars Claim Status is Closed Jurisdiction is an Impairment State Impairment Percentage Basis Code is 2 Claims where (within the date range): Lump Sum Benefit Type or Periodic Benefit Type is 03, 04, 09, or 50 Corresponding Benefit Paid Amount is greater than zero dollars Claim Status is Closed Jurisdiction is an Impairment State Impairment Percentage Basis Code is 1 Observation Notes If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, it is unusual for a large percentage of claims to have an impairment percentage of 1% or 2% for a part of body. Download the extract of these claims and review to determine whether the impairment percentages are correct. If the percentage of claims is significantly different from the industry norm, download the extract of these claims and review to determine whether the impairment percentages are correct. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

45 PART 10 Page 6 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook Element Name Maximum Medical Improvement (MMI) Date Maximum Medical Improvement (MMI) Date Medical Extinguishment Indicator Observation Description MMI Date = Closing Date Accident Date to MMI Date < 31 Days Medical Extinguishment Indicator = Y Claims Observed Claims where, within the date range, the Benefit Type Paid or Lump Sum Benefit Type Paid for Benefit Type 02, 03, 04, or 50 is greater than zero dollars. Claims where (within the date range): MMI Date is a valid date and the Claim Status is Closed MMI Date is not equal to the Closed Claim Date Benefit Type Paid or Lump Sum Benefit Type Paid for Benefit Type 02, 03, 04, or 50 is greater than zero dollars Claims where: Medical Extinguishment Flag equals Y Incurred Medical Amount Total minus Total Paid Medical Amount is greater than $1,000 Claim Status is Closed Lump Sum Amount Paid is greater than Observation Notes MMI Date typically corresponds to the determination of Permanent Partial Disability benefits. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, download the extract of these claims and review to determine whether the MMI Dates being reported are correct. Review to determine whether the Closing Date is being reported as the MMI Date when the MMI Date is unknown. It is unusual for a Permanent Total or Permanent Partial Disability claimant to reach an MMI Date within a month. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, download the extract and review the claims with the largest Benefit or Lump Sum payments and review to determine whether the MMI Dates being reported are correct. This indicator is set to Y when the medical payments are extinguished based on a lump sum settlement agreement. If the indicator is set to Y, we would not expect to see the Medical Incurred Amount to be greater than the Medical Paid Amount. If the percentage of claims is significantly different from the industry norm, download the extract for these claims and review to determine whether either of the two medical paid amounts is incorrect or whether the Medical Extinguishment Indicator was set to Y in error. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

46 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 7 Element Name Preinjury Wage Amount Return to Work Date Observation Description Preinjury Wage Amount < $100 or > $5,000 Return to Work Date Accident Date < 4 Days Claims Observed zero for any Lump Sum Benefit Type Code (02, 03, 04, 05, 06, 09, 11, 12, 15, 49, or 50). All claims within the date range. Claims where: Benefit Type equals 05 (Temporary Total Injury) or Benefit Type equals 11 (Temporary Partial) and Lump Sum Amount Paid and Benefit Amount Paid are greater than $100 Benefit Type equals 01 (Death) or Benefit Type equals 02 (Permanent Total Observation Notes If the indicator is set to Y for 100% of the claims, verify that the indicator is being populated on a per-claim basis. It is unusual to see large percentages of claimants with either very LOW or very HIGH Preinjury Weekly Wages. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, download the extract of these claims. For claims with LOW Preinjury Wages, sort the extract by the Indemnity Incurred amounts (largest to smallest) and review those with the largest Indemnity Incurred amounts to determine whether the claimants Preinjury Weekly Wage has been reported correctly. Likewise, for claims with HIGH Preinjury Wages, sort the extract by the Indemnity Incurred amounts (smallest to largest) and review those with the smallest Indemnity Incurred amounts to determine whether the claimants Preinjury Weekly Wage has been reported correctly. In many states, a claimant is not compensated for time off work (e.g., Temporary Total or Temporary Partial Disability benefits) unless they are out of work for longer than the waiting period as defined by the state. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, download the extract of these claims and review to determine that the claims have not been reported using the Accident Date as the Return to Work Date when the Return to Work Date is unknown. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

47 PART 10 Page 8 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook Element Name Observation Description Claims Observed Disability) and Lump Sum Amount Paid plus Benefit Amount Paid is less than $100 Claim Status is Closed Return to Work Date is a valid date within the date range Return to Work Date Return to Work Date Missing Claims where (within the date range): Benefit Type equals 05 (Temporary Total Injury) or Benefit Type equals 11 (Temporary Partial) and Lump Sum Amount Paid and Benefit Amount Paid are greater than $100 Benefit Type equals 01 (Death) or Benefit Type equals 02 (Permanent Total Disability) and Lump Sum Amount Paid plus Benefit Amount Paid is less than $100 Claim Status is Closed Observation Notes If a claimant has returned to work and the data is available but not provided, our ability to evaluate the effectiveness of return-to-work programs is reduced. Ensure that the Return to Work Date is reported accurately. If you are in Group 1 or 2, you are likely reporting correctly. If you are in Group 4 or 5, download the extract of these claims and review to determine that the claimants Return to Work Date is being populated whenever appropriate. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

48 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 9 Element Name Return to Work Rate of Pay Indicator Vocational Rehabilitation Other Paid Observation Description Return to Work Rate of Pay Indicator = N Vocational Rehabilitation Other Paid > 0 Claims Observed Claims where: Benefit Type Paid or Lump Sum Benefit Type Paid for Benefit Type 03, 04, 05, 09, or 50 is greater than zero dollars Return to Work Date is a valid date and is not blank within the date range All claims within the date range. Observation Notes A value of N indicates that the claimant has returned to work at something other than the same or similar preinjury hours and pay. If the percentage of claims is significantly different from the industry norm, download the extract for these claims and review the claims where the preinjury and postinjury weekly wages are the same. Determine whether these claims should have been reported with a Return to Work Rate of Pay Indicator = Y. If the Carrier % is either 0% or 100%, ensure that the indicator isn t defaulted to Y or N for 100% of your claims. The Vocational Rehabilitation Other Paid field is used when types of payments are not specifically part of the other Vocational Rehabilitation elements. It is unusual to have a high percentage of dollars in this field because most Vocational Rehabilitation payments would fit into one of the other three Vocational Rehabilitation elements. Ensure that the correct Vocational Rehabilitation code values are reported accurately. Download the extract and sort from largest to smallest. Review the claim with the largest Vocational Rehabilitation Other Paid amounts. Compare this amount to the other Vocational Rehabilitation payment types and determine which, if any, need to be corrected. Recommendation: If you are going to download an extract to review the claims making up an observation and the number of claims for the observation is large, decrease the time frame. This will make the number of claims more manageable for your review. Note: If your carrier results for any of the 18 observations above do not fall into Group 3, this does not mean that your results are incorrect. The DCI Quality Observations feature is designed to recommend areas for your review only. 2. Benefit Type Observations Benefit Type Observations are state-specific and based on the periodic and/or lump sum payments for the following benefit types: Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

49 PART 10 Page 10 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook Benefit Type 03 Scheduled Permanent Partial (defined as Impairment Benefits in Florida) or Supplemental Income Benefits (SIBs) (TX only) Benefit Type 04 Unscheduled Permanent Partial or Impairment Income Benefits (IIBs) (TX only) or Compensation for Permanent Partial Disability (NH only) Benefit Type 09 Disfigurement Benefit Type 15 Supplemental (LA and SD only) Benefit Type 50 Other Specified Indemnity Benefits Discretionary Benefits (CT only) Permanent Total Disability Supplement Benefits (LA and RI only) Additional Benefits (LA and RI only) Each state-specific Benefit Type Observation provides the following information: Delta % Carrier % of claims with periodic and/or lump sum payments minus Industry % of claims with periodic or lump sum payments Claims Number of the carrier s claims with periodic and/or lump sum payments across the five benefit types States are sorted by: Calculating the absolute value for Delta % for each of the benefit types by state Determining which of these is the maximum Delta % for the state Arranging states in descending order by their maximum Delta %; if there is a tie, displaying those states alphabetically Showing all states that are below the minimum claim threshold alphabetically at the bottom Note: If number of claims falls below threshold, then LCV or Low Claim Volume will display. Also provided at the State and Benefit Type levels are the following: Usage Comparison (bar chart) Compares the percentage of use of periodic payments versus lump sum payments for both the carrier and the industry Carrier % of Periodic Payments is determined by the number of claims with periodic payments only for a state and benefit type as compared to the number of claims with payments for the state across all benefit types Carrier % of Lump Sum Payments is determined by the number of claims with lump sum payments for a state and benefit type as compared to the number of claims with payments for the state across all benefit types Industry % of Periodic Payments is determined by the number of claims across all carriers with periodic payments for a state and benefit type as compared to the number of claims with payments for all carriers for the state across all benefit types Industry % of Lump Sum Payments is determined by the number of claims across all carriers with lump sum payments for a state and benefit type as compared to the number of claims for all carriers with payments for the state across all benefit types Median Payments Comparison Provides the median Periodic Amount and the median Combined Periodic and Lump Sum Amount by Carrier and by Industry Observation Notes: State Results A positive Delta % indicates that the carrier is making a higher percentage of payments for that benefit type than the industry. Conversely, a negative Delta % indicates that the carrier is making a lower percentage of payments for that benefit type than the industry. If you notice a large positive Delta % in one benefit type and a similar negative Delta % for a different benefit type, it is possible that you have swapped the mapping of your payment codes to the Benefit Type Codes. Download the extract for these claims and review to ensure that the mapping of payment codes to the Benefit Type Codes is correct. Periodic vs. Lump Sum Graph Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

50 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 11 Similar to the State results, if you notice a large difference in the use of different benefit types between the carrier and industry results, it is possible that you have swapped the mapping of your payment codes to the Benefit Type Codes. Download the extract for these claims and review to ensure that the mapping of payment codes to the Benefit Type Codes is correct. If you notice a large difference in the use of periodic vs. lump sum payments between the carrier and industry results, it is possible that you have swapped the mapping of your type of payment codes to the Periodic vs. Lump Sum Payment arrays. Download the extract for these claims and review to ensure that the mapping of payment codes to the Periodic vs. Lump Sum Payment arrays is correct. Median Payments Comparison If the carrier result is 0 for periodic payments and >0 for periodic and lump sum payments, then this should correlate to the payment graphs for 0% carrier periodic payments and >0% for lump sum payments If the carrier result is >0 for periodic payments and the same amount for periodic and lump sum payments, then this should correlate to the payment graphs for >0% carrier periodic payments and 0% for lump sum payments Recommendation: If you are going to download an extract to review the claims making up a state and the number of claims for the state is large, decrease the time frame, which will make the number of claims more manageable for your review. Note: If your carrier results for any of the state/benefit type combinations are not similar to the industry results, this does not mean that your results are incorrect. The DCI Quality Observations feature is designed to recommend areas for your review only. Through the new feature, you can download extracts of the specific claims that make up the carrier results for each observation. These extracts contain claim-specific details that relate to each specific observation. For more details on available DCI Quality Observations extracts, refer to Item D Claim Extracts in this part of this guidebook. 3. Attorney Indicator Observations The Attorney Indicator Observations are state-specific and based on the reporting of the Attorney or Authorized Representative Indicator being reported as Y, which indicates that the claimant has an attorney or authorized representative. Attorney Indicator Observations include: Claims that are open at 18-month valuation Claims that are closed at the latest valuation Each State-Specific Attorney Indicator Observation provides the following information: Carrier % Percentage of claims reported with noted observation by carrier group. Industry % Percentage of claims reported with noted observation for all carrier groups. Percentile Evaluation of the percentage of carrier data versus industry data segregated into five percentile groupings. The groupings are sorted per the table below, with the observations that are the furthest from the industry norm first. Any observations that fall below the individual observation threshold for claim volume will always be sorted to the bottom. Group 1 Carrier % is within the 0 10th percentiles. Observations in this range are well below the industry average and are worth reviewing and monitoring, except where noted in the Observation Notes. Percentile Groupings Group Evaluation Sort Order Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

51 PART 10 Page 12 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook Group 2 Carrier % is within the 11th 33rd percentiles. Observations in this range are slightly below the industry average and may be worth reviewing, except where noted in the Observation Notes. Group 3 Carrier % is within the 34th 66th percentiles. Results within this group are considered to be the norm; therefore, you can assume that these results do not need to be reviewed. Group 4 Carrier % is within the 67th 89th percentiles. Observations in this range are slightly above the industry average and may be worth reviewing. Group 5 Carrier % is within the 90th 100th percentiles. Observations in this range are well above the industry average and are worth reviewing and monitoring. Claims Total number of claims by Received Date or Reported to Insurer Date with noted observation based on time frame requested. Note: If the number of claims falls below threshold, then LCV or Low Claim Volume will display. Observations are sorted as follows: At the state level By the combined difference between the Carrier % and the Industry % across the two observations for each state The states with the greatest combined difference are at the top, while those with the least are at the bottom Observation Notes: State Results If a particular state and observation combination is in Group 1 or 2, you have fewer claims than the industry with the Attorney Indicator = Y ; download the extract If you do report Claimant Legal Paid, filter to only show claims where the Claimant Legal Paid amount > 0; review these claims because they likely should have the Attorney Indicator = Y If you do not report Claimant Legal Paid, filter to only show those claims with Attorney Indicator = N Then sort either the Total Medical Paid or Total Medical Incurred column from largest to smallest Review the claims with the largest Total Medical Paid/Incurred to verify whether these claims should have had the Attorney Indicator = Y If a particular state and observation combination is in Group 4 or 5, you have more claims than the industry with the Attorney Indicator = Y ; download the extract If you do report Claimant Legal Paid, filter to only show claims where the Claimant Legal Paid amount = 0; review these claims because they possibly should not have the Attorney Indicator = Y If you do not report Claimant Legal Paid, filter to only show those claims with Attorney Indicator = Y Then sort either the Total Medical Paid or Total Medical Incurred column from smallest to largest Review the claims with the smallest Total Medical Paid/Incurred to verify whether these claims should have had the Attorney Indicator = N Recommendation: If you are going to download an extract to review the claims making up a state/observation combination and the number of claims is large, decrease the time frame to make the number of claims more manageable for your review. Note: If the carrier results for any of the states for either of the two observations do not fall into Group 3, this does not mean that your results are incorrect. This DCI Quality Observations feature is designed to recommend areas for your review only. Through the new feature, you can download extracts of the specific claims that make up the carrier results for each observation. These extracts contain claim-specific details that relate to each specific observation. For more details on available DCI Quality Observations extracts, refer to Item D Claim Extracts in this part of this guidebook. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

52 Detailed Claim Information Reporting Guidebook Issued May 30, 2017 PART 10 Page 13 C. VALUATION OBSERVATIONS Valuation Observations identify claims where the Paid Periodic or Combined (Periodic and Lump Sum) Benefit Type Amount Paid is reduced at a later valuation based on comparison across all submitted valuations. The Valuation Observations category includes: Reduced Periodic Payments Reduced Periodic and Lump Sum Payments (Combined Benefit Payments) Each observation will provide results based on a predetermined time frame. Users have to set the Start and End dates to query results based on either the Received Date or Reported to Insurer Date ranges. 1. Reduced Periodic Payments Claims where the carrier has made weekly payments for a particular benefit type to the claimant only, and the total amount of these payments has decreased from one valuation to the next. 2. Reduced Periodic and Lump Sum Payments (Combined Benefit Payments) Claims where the carrier has made at least one lump sum payment for a particular benefit type to the claimant, and the total of both lump sum and weekly payments has decreased from one valuation to the next. The screen will display the following information for all claims meeting the criteria selected: Claim Number Policy Number Carrier Code Reported to Insurer Date Policy Effective Date Recommendation: If you are going to download an extract to review the claims making up a state/observation combination and the number of claims is large, decrease the time frame to make the number of claims more manageable for your review. Observation Notes: Through the new DCI Quality Observations feature, you can download extracts containing additional claim level details. Unlike the other extracts, the extract for both the Reduced Periodic Payments and the Reduced Periodic and Lump Sum Payments (Combined Benefit Payments) has an additional column that is not a DCI data element. This additional column, BENEFIT TYPE W REDUCTION, is used to indicate which claim valuation and the associated benefit type payments have a reduction from the prior valuation. For details on available DCI Quality Observations extracts, refer to Item D Claim Extracts in this part of this guidebook. D. CLAIM EXTRACTS Claim extracts can be generated through the DCI Quality Observations feature. To receive a report, check the selection box on the left-hand side of the displayed results on any of the observation screens and then click Download. Details are provided in an Excel spreadsheet. On the General Observation screens, you may select up to six observations per download On the Valuation Observation screen, there is no limit to the number of claims you can select to download Following is a sample screenshot of a report generated from the Attorney Indicator Observations in the DCI Quality Observations feature in the DCI Data Collection tool. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

53 PART 10 Page 14 Issued May 30, 2017 Detailed Claim Information Reporting Guidebook For details on available DCI Quality Observations extracts, refer to DCI Quality Observations Extracts. Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.