Digital Investigations: An Inside Look - Training, Saturday, January 24, 2015

Digital Investigations: An Inside Look, January 24, 2015 https://t.co/5u5KFjgkJe

— Ryan D. Clock (@PrecisionPI) December 23, 2014

The 6th Thing That A California Investigator Needs…

from their worker's compensation adjuster/examiner is an

EDEX and a Claims Index Report

So what is an EDEX?  EDEX stands for Electronic Data Exchange System.  This system is employed by the California State Division of Worker's Compensation as a means for permissible end users to request and receive data through purchase regarding worker's compensation cases that are under the jurisdiction of the California Worker's Compensation Appeals Board (WCAB).  The Worker's Compensation Appeals Board is the judicial administrative board that hears and resolves disputes on worker's compensatio cases between an applicant and the defendant insurance company or employer.  The WCAB also issues awards for benefits to those applicant's that are entitled to those benefits.

When I say "under the jurisdiction" of the WCAB, I mean only cases in which pleadings have been filed with the board (i.e. Application for Adjudication, Stipulation with Request for Award, Compromise & Release, etc.).  EDEX will only have data on cases in which these have been filed.  EDEX will not have any data on any claim that has not been filed with the WCAB.  Claims not filed with the WCAB may include incident only files (no medical treatment, no lost time), medical only files, files that do not have any settlement, and other new or ongoing indemnity claim files in which the claimant and the claims administrator may or may not be represented and have not filed any of the initiating documents named above.

Investigators may obtain the EDEX report from their adjuster clients but may also obtain them directly from the authorized approved vendors if they have a permissible reason.  See the vendors below (http://www.dir.ca.gov/dwc/edex.html)

Information brokers::

Company

Phone #

Fax #

Website Address

CompData EDEX & EAMS Services

P.O. Box 729
Seal Beach
CA 90740

(562) 493-4000

(562) 493-1550

http://www.compdataedex.com

Computer Services Group

1927 Harbor Blvd. #395

Costa Mesa, CA 92627

(800) 798-1880

(949) 646-7029

http://www.csg2000.com

EDEX Information Systems, Inc.

P.O. Box 665
Jackson, CA 95642

Toll-free

(866) GET-EDEX

(866) 438-3339

(209) 231-6700

http://www.edexis.com

Grey Wolf Laboratories Wolf Schubert

4006 Claitor Way
San Jose CA 95132

(408) 904-8731

http://greywolflabs.com

wolf.schubert@greywolflabs.com

Medical Lien Management, Inc.

P.O. Box 6829

Norco, CA 92880

(951) 808-3054

(760) 406-4807

http://www.dwcexchange.com/info@dwcexchange.com

SpeedComp EDEX & EAMS Services

P.O. Box 6886
Malibu, CA 90264-6886

(310) 457-3300

(310) 457-0500

http://wcabonline.com

Workcompcentral

1320 Flynn Rd.
Ste. 403
Camarillo, CA 93012

Toll-free

(866) WRK-COMP

(866) 975-2667

(805) 484-9322

http://www.workcompcentral.com

Inquiries are made with the EDEX system by submitting the claimant's Social Security Number and/or WCAB Case number (aka EAMS Number).  EDEX data can provide the following information:

Claimant's Name

Claimant's Date of Birth

Claimant's Gender

ADJ (EAMS #) or legacy WCAB Case Number

Body Parts Claimed

WCAB Current Case Status

The last five recent significant case events with dates.

A list of any hearings both past and future.

The official address record for each party to the case filing

Claims administrator

Insurance company if different from the claims administrator

Claimant's attorney

Defense attorney

Applicant's attorney or representative

Lien claimants

WCAB Jurisdictional Location (i.e. San Jose, San Francisco, Los Angeles, San Diego, etc.)

Date of the claimed injury

Type of injury (i.e. specific injury, cumulative trauma, occupational illness/disease)

The above vendors offer access to EDEX information as a fee for service.

The Division of Worker's Compensation also has a "free" public search tool to obtain similar information above but it is more limited in what it provides and depending on the credibility of the search criteria may not provide all available results.  This free search tool is called the EAMS (Electronic Adjudication Management System).

Information about the tool and its capabilities can be found at the following link:  (http://www.dir.ca.gov/dwc/eams/EAMS_PublicInformationSearch.htm)

The following is language is taken from the California DWC's Website regarding the public search tool:

"Requestors can search on all cases, including archived cases. If the case is archived the archived box will be checked on the general case information screen. If a Disability Evaluation Unit (DEU) case exists, the DEU box will be checked on the general case information screen. This is for informational purposes only—no DEU information is provided through this search.

Other criteria include:

Minimum search criteria is the EAMS case reference number or injured worker name

Partial name search is allowed

Date of birth, city, and ZIP code can be used with injured worker first and last name to refine search

Search result will be limited to 50 body part codes, active participants and events.

Since search results are limited to 50 it is best to be as specific as possible when searching. If the EAMS case number is not known, but the legacy case number is known, the EAMS and legacy case number lookup tool can be used to find the EAMS case number."

The search tool may be accessed by the following link:  https://eams.dwc.ca.gov/WebEnhancement/

On this screen the requester of the information must provide their information.  Their first and last name, a Uniformed Assigned Name (UAN) if one was assigned, their e-mail address, and then select a reason for their inquiry.  A private investigative firm will not likely have a UAN.  You would not have a UAN unless you have requested one.  These UANs are usually reserved for attorneys, law firms, insurance companies, and/or claims administrators.

After entering your information and clicking submit you will be brought to the next screen.  There are two tabs:  Case Search and Lien Search.  For the purposes of this blog posting we will only be presenting the Case Search tab.  There are six search fields.  Three of the search fields have an asterisk next to them.  At minimum you must enter an EAMS Case number or claimant's first and last name.  If you are searching by name you may input a partial name in either or both the first name or last name field.  The public information tool differs from the EDEX search in that you cannot search by Social Security Number.  In addition, as with all databases, if the incorrect information is initially entered or misspelled than it will be more difficult to find the information that you are looking for.

CLAIMS INDEX:

Obtaining a claims index report is a means to not only uncover prior worker’s compensation injuries but also uncover other personal injury claims that the claimant may have been involved with such as auto accidents, slip and falls, property claims, and general liability claims.   The claims index often also called ISO Claims Index because ISO is the largest vendor for this service.  The claims index is a database that many insurance companies and third party administrators subscribe to.  These members submit data on claims they receive from their insured, claimants and or third party claimants to add to the database.  Later they can search the database for claims history that may be pertinent to a current claim for the purposes of combating fraud, abuse, and mitigating loss on future claims that are filed.  One of the downsides of the index system is that not all insurers and claims administrations provide their claims data to the data base.

When a claim is submitted by an insurer or third party administrator the system searches the database and pulls claims information that matches any individual information or a combination of information submitted.  For example hits will be generated if there are matches in the claimant’s name, claimant’s address, claimant’s phone number, claimant’s date of birth, Vehicle Information Number, Vehicle license number, tax identification number, other parties to the loss, and/or the claimant’s Social Security Number.

Typically claims index information is only available to insurers, self-insured entities, and third party claims administrators.  That is why this information should be obtained from your client insurer, self-insured employer, or third party administrator.

For more information on the ISO Claims Index check out the following link: http://www.iso.com/Products/ISO-ClaimSearch/ISO-ClaimSearch-Facts-and-Figures.html

Why are the EDEX & the Claims Index Important for the Investigator?

Can be used to identify possible fraud.  Can be used with questioning a claimant regarding prior claims and injuries to see if they are forthcoming regarding those claims prior to asking them directly about them.  Can identify claims history that may not necessarily uncover fraud, but provide an apportionment to a preexisting disability.  Can be used to identify prior or concurrent employment.

Posted via Blogaway

The 3rd thing that a California investigator needs…

to obtain from their claims adjuster in the process of their worker’s compensation investigation is the:

Doctor's First Report of Injury or Illness (Form 5021)

Within five days of an injured worker's initial medical examination, for every occupational injury or illness, the injured worker's Primary Treating Physician, hereafter referred to as the PTP must complete and issue this form.  If the injured worker changes their PTP, their new PTP will also need to complete this form.  The PTP must then send two copies of this report to the employer's workers' compensation insurance carrier or their worker’s compensation claims administrator.  If the physician fails to file a timely report it may result in assessment of a civil penalty against the physician.

The PTP is defined in the California Code of Regulations Title 8 Section 9785(a)(1) as, "the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter."  This PTP is the sole physician who is responsible for determining the injured worker’s disability status and managing the medical treatment.  A further description of the duties of the PTP can be found Title 8 CCR Section 9785.

The PTP can initially be selected by the employer, usually the physician at their designated industrial condition.  This is especially the case if the injured worker has not pre-selected their own personal physician prior to the date of the injury or the onset of illness.  If the injured worker has not predesignated their own personal physician to treat them in case of a work related injury and their employer has a State approved Medical Provider Network (MPN) in place, then the injured worker is required to treat with a physician within the Medical Provider Network.  If by chance the injured worker’s personal regular physician is in the MPN then the worker may select their physician.

Now we come back to the form itself.  The form is divided into twenty-seven sections.  The first twenty-six sections are numbered.   The final section has the doctor’s information and signature.  There is a wealth of information that can be obtained from a careful review of this document by the investigator.  This information can refute or corroborate other information obtained through your investigation.  While all the information may be important, I suggest the investigator focus on sections 5 through 26.  In these sections, you will uncover what the injured worker told the doctor, the date of time of the injury, where they were injured and how they were injured.   In box 16, the medical provider has to disclose whether or not they have treated the injured worker before.  Box 17 will list the injured worker’s subjective complaints (i.e. pain, numbness, dizziness, etc.).  Boxes 18 – 24 list the physician’s findings on their examination of the injured worker.  Things like objective findings (i.e. loss of range of motion, x-ray or MRI results, laboratory results, etc.), the physician’s diagnosis including assigned ICD-9 Diagnosis Codes, and whether or not the physician in his opinion feels that the diagnoses rendered are consistent with injured worker’s account of the injury.  Thereafter, the physician must disclose if there are any current conditions that will impede or delay the injured worker’s recovery from their work injury.  This is a place where the physician may disclose a non-work related condition such as diabetes, a condition which often slows down an injured worker’s recovery from an injury.  The physician then is to describe what treatment was rendered during the office visit (box 23) and then advise if any further treatment is recommended to cure or relieve the effects of the injury or illness (box 24).  In box 26, the physician has to provide the injured worker’s work status (the injured worker’s ability to return to work).  The physician will indicate if the worker is able to return to their regular job or whether or not temporary work restrictions are necessary and what those restriction are.  If the injured worker is not capable of returning to any work at the time of the evaluation, the physician will likely just write in this section either “off work” or “TTD” which means Temporary Total Disability.  Finally, the physician must sign the report, type or print their name and address and their degree (MD, DO, DPM, etc.), their medical license number, their Federal Tax Identification number, and their office or direct telephone number.

As a side note, the more claimant profile and background that you provide to the assigned adjuster/examiner regarding the claim you are investigating, the better their estimate will be for the claim’s reserves or the money that an adjuster allocates to a claim file for reasonable anticipated benefit and/or expense payments on that file.  This will make the actuaries, the employer’s, the insurance companies, and the state regulatory agencies happier when a claim is properly adjusted according to the principle of anticipated probable financial outcome.

If you have any questions or comments about the information contained in this blog, you can enter it in the section at the end of the post that says "Post A Comment."  If you have any ideas about future topics you can e-mail them to me directly at GetTruth@precisiondetective.com.

Please feel free to share this information with your friends or colleagues.

Stay tuned for the next installment of this California Worker's Compensation series by

The Precision Detective

The 2nd thing that a California investigator needs…

The 2nd document that a worker's compensation investigator should obtain from the claims adjuster before beginning their investigation is a completed Form 5020, known as the Employer's First Report of Injury or Illness.

Employer's First Report of Injury or Illness (Form 5020)

California law requires all employers to report to their claims administrator within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident or requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition to the completing of the 5020, every serious injury, illness, or death must be reported immediately by telephone or other means to the nearest office of the California Division of Occupational Safety and Health.  Once the Form 5020 is reported to the claims administrator, the claims administrator must report the information contained in the document to the California Department of Insurance via EDI (Electronic Data Interchange) per Title 8, California Code of Regulations Section 14002.

It is important for the investigator to note that this form contains confidential information that should only be disclosed to persons who are entitled to this information as per CCR Section 14300.35, 14300.30, & 14300.40.  The investigator should make sure they protect the confidential information from being disclosed to a party who is not permitted to view or learn of the information.

The Employer's First Report can provide the investigator a wealth of information to assist them in developing their investigation into the facts of the incident which resulted in injury or illness.  The form contains 39 boxes of information divided into three sections:  The Employer, The Injury or Illness, & The Employee.

In the employer section, the investigator should pay particular attention to box 4 and box 6.  Box 4 tells the reader of the document the nature of the employer's business.  Box 6 tells of the reader the type of employer (i.e. Private Employer or various public employers).  The nature of the employer's business (i.e. restaurant, hotel, construction company, etc.) will inform the investigator what range and types of employees the employer likely has working for them.  Knowledge of the employer type will assist the investigator in identifying possible special issues that will need to be investigated to provide the information to the adjuster so they may make the appropriate determinations on liability and benefit eligibility.  These issues may include (applicability of Educational Code Benefits, applicability of presumptions of injury for certain employee types, applicability of Labor Code Section 4850 benefits, etc.)

The second section is the injury or illness section (boxes 7-29).  This sections contains a wealth of information that can be used in the process of investigation.  Of course, I recommend the investigator verify the information contained in the document with the person who completed the document as well as independently corroborate the information from other sources.  This section tells the investigator and/or the claims adjuster the basic information relating date and time of injury, place of injury, whether or not there was any lost time, has the employee returned to work, when was the employer's first date of knowledge of the injury, whether or not any chemicals or equipment was involved in the injury, description of the activity the injured worker was performing at the time of injury, a description of how the injury or exposure occurred, the name of the physician or medical facility that treated the injured worker, and whether or not the employee was treated in the emergency room or if they were hospitalized overnight.  All of the information is crucial to the proper adjusting of a California Worker's Compensation claim.

The final section of the 5020 is the employee section (boxes 30-39).  The employee section provides basic demographic information for the injured worker that includes their name, date of birth, Social Security Number, address, phone number, employee status, usual work hours, occupational title, date of hire, salary/wages, and whether the injured worker is eligible for other means of compensation (i.e. tips, lodging, meals, bonuses).

The investigator should obtain a copy of this document from the employer if they did not receive one from the claims adjuster.

The Employer's First Report of Injury or Illness is one of the documents mandated by state law and regulation to be housed in a paper or electronic claim file and available for inspection by state regulatory audit agencies.

Should any of the readers have any questions about this document, please feel free to post your question to the blog or e-mail me directly.  Thank you for your interest in this subject.

Stay tuned for the next installment of this California Worker's Compensation Claim Investigator Series.  Should you wish to be notified of any new postings on this blog, please subscribe on the right hand column.

Leaving No Stone Unturned!

Ryan D. Clock, The Precision Detective

The 1st thing that a California investigator needs…

Welcome to the first installment of the California Worker's Compensation Blog Series for claims investigators and worker's compensation claims professionals,

" The 9 Things An Investigator Needs From Their Claims Adjuster "

The first thing an investigator needs to obtain from their claims adjuster or the employer if not available from the claims adjuster is the injured claimant's worker's compensation claim form or (DWC - 1) & Notice of Potential Eligibility .

DWC-1 (Click Here to View and/or Save Form for Reference)

California Labor Code Section 5401(a) states as follows:

"Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, which injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits under this division to the injured employee, or in the case of death, to his or her dependents."

Labor  Code Section 5402(a) states that "(a) Knowledge of an injury, obtained from any source, on the part of an employer, his or her managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400."

The California Worker's Compensation Claim Form (DWC-1) is the cornerstone form of the California Worker's Compensation System.  The filing of this form is meant to start the process into determining whether a claimant's claim for benefits will be accepted.  The provision of the claim form by the employer to a suspected injured worker and that injured worker's submission of that completed claim form to the employee begins the 90 day period in which the claims administrator has the opportunity to investigate the facts of the claim and make a determination whether to accept a claim or deny a claim in whole or in part.

The claim form (DWC-1) can provide the introductory information into the nature of the claim being made by the claimant or injured worker.  The claim form package including the notice of potential eligibility is divided basically into three sections.  The first section is the Notice of Potential Eligibility.  The notice of potential eligibility contains information in English & Spanish addressed to the injured worker regarding their rights and responsibilities under California Worker's Compensation law and describes benefits that the injured worker may be eligible for.  The second section is the employee’s section of the actual claim form, sections 1 through 8.  This section is only to be completed only by the employee or their authorized representative.  The third and final section is the employer’s section, sections 9-18.  The employer is to complete this section only after the employee has completed sections 1 through 8.  The employer is then to return a fully completed document copy to the injured worker and then also provide a copy to the employer's claims administrator.

It is imperative for the investigator and claims adjuster to verify the information contained in the Employee's Claim Form to make sure it is correct.  I recommend that an investigator and/or claims adjuster discuss the contents of the form with the persons who completed the form to verify the forms accuracy.  I also recommend that if a recorded statement is being taken of the claimant, that the claimant acknowledge on the recording what parts of the form that they completed and to acknowledge in the negative or affirmative that they read and understand the document inclusive of the Notice of Potential Eligibility Language.  Furthermore, I also make it a habit to have the claimant acknowledge the anti-Fraud statement which states as follows:

“Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony”.


This may elicit a guilty conscience for those claimant’s who may be misrepresenting their claims in whole or in part and may cause them to rethink the filing of their claim.


Join me next week for the next installment in this series to find out the 2nd thing you need prior to starting your investigation.


Until then,


Ryan D. Clock, The Precision Detective

New California Worker's Compensation Investigation Blog Series Announced

In my experience as a California Worker's Compensation Senior Claims Examiner I have learned that having the most appropriate and the most correct information is imperative in order to begin and end an investigation into a worker's compensation claim.  As a result, I have come up with at least 9 things an investigator needs from the claims adjuster prior to completing their AOE/COE or other associated worker's compensation claims investigation.


Therefore, I will be beginning this week I will be writing a weekly blog series entitled,

" The 9 Things The Investigator Needs From Their Claims Adjuster "

So come join this Truth Slueth weekly as I unpack these 9 things by subscribing or following my blog.  You can do so by signing into blogger, subscribing to the RSS feed, or subscribing by e-mail below.


Along the way you will have opportunity to make comments and/or ask some questions about the week's topic.  We can share personal stories as well as personal challenges.  I may also be able to provide you some insight into the realm of the claims adjuster and insight into why they do the things that they do or why they do not do the things you would expect them to do.


You can find me on twitter at @PrecisionPI, on Facebook as Long Beach Private Detective.  My website is currently under construction, but you can find it at www.precisiondetective.com.  You can click on any of the tabbed links above to take you those sites directly.


I look forward to seeing you participate in this and future blog series and posts.  Should you require more detailed response to a questions or require a consultation, you can reach me by phone at 562-502-7053 or at GetTruth@PrecisionDetective.com.


Get Truth!


The Precision Detective, Ryan D. Clock (PI 26879)