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Transcription 1 Annual Report S ystem Performance This section reviews the performance of New Mexico s insurance carriers and self-insurers in paying and reporting indemnity claims and employers performance in reporting injuries.
Its purpose is to provide a better understanding of the quality of services provided by participants in New Mexico s workers compensation system, to recognize what they are doing well and what they can improve. The measures in this section look at how quickly: Employers notify their insurance carrier or self-insurer about an injury Insurers start paying indemnity benefits Injuries and indemnity claims are reported to the WCA.
Prompt Initial Payment of Indemnity Benefits One of the goals of New Mexico s workers compensation system is the quick and efficient delivery of indemnity benefits to injured and disabled workers, NMSA This is an obligation of payers that can lessen financial hardship on injured workers and reduce the likelihood of litigation and regulatory penalties against insurers.
Indemnity benefits are payable in New Mexico when the workrelated disability results in more than seven days of lost time from work. The delay between the eighth day of disability and the first indemnity payment is a useful indicator of how promptly benefits are delivered in New Mexico.
Overall, insurers made 74 percent of first indemnity payments within 21 days after the eighth day of disability for injuries in They made 64 percent of the payments within 14 days after the disability date. The performance of individual insurers varies widely, and the WCA is mandated by statute to publish a list of insurers who have been late in making first indemnity payments, ANMSA Table 21 shows those insurance carriers and selfinsurers who made payments two weeks or more after the eighth day of disability.
For example, the insurer may not be at fault when payments are postponed because the workers compensation court must decide compensability issues. Two insurers delayed an unusually large share of first indemnity payments for two years in a row.
The City of Santa Fe delayed 87 percent of their initial indemnity payments for two weeks or more after the eighth day of disability in All of their initial indemnity payments were late in Fremont Indemnity Company was late in making 66 percent of their initial indemnity payments in Approximately 86 percent of their initial indemnity payments were late in Two insurers stand out at the other end of the scale for promptly paying first indemnity benefits for two years in a row.
A number of factors contribute to differences among jurisdictions, including variation in requirements regarding the statutory payment period, the insurer s option to make provisional payments, state imposed penalties and other enforcement initiatives.
Payers can make the first indemnity payment sooner when they have efficient processes for investigating an injury, determining compensability, calculating benefits, and reserving funds.
In most cases, these processes can start as soon as the payer knows about the injury. Therefore, the interval between payer notification and the first indemnity payment is a useful measure of this kind of efficiency. Fifty-four percent of first indemnity payments in New Mexico were made within 14 days after the payer was notified of the injury.
Prompt Notification of Injury to Payer Timely payment depends in part on employers promptly notifying their insurers when an injury or illness occurs. Thirty-five percent of the payers were notified within 3 days of employer notification in New Mexico compared to an average 52 percent among states in the WCRI study Telles, et al.
The accuracy of the WCA s statistical reports depends so heavily on the quality of these submittals that their timeliness and completeness are themselves performance measures.
By statute, payments are considered late if the Notice of Benefit Payment is filed more than 14 days after the First Report of Injury or Illness.
No attempt was made to exclude cases with extenuating circumstances that may relieve the employer or insurer of fault for apparent late payment. The largest share of First Reports is submitted to the WCA within two weeks after the employer was notified of the injury, and most are sent through EDI, as Table 22 indicates.
Non-Filing of Notices of Benefit Payment Insurers sometimes fail to report payments on indemnity claims, and the WCA identifies those cases in which benefits have been ordered or agreed upon in dispute resolution. The WCA has identified of these cases sinceas Table 23 shows.
The WCA requests claims information from the insurer when cases like these are identified, reminding them of statutory reporting requirements. Co General Insurance Co. Group Health South Rehab.
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Medical provider networks A medical provider network (MPN) is an entity or group of health care providers set up by an insurer or self-insured employer and approved by DWC's administrative director to treat workers injured on the job.
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