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Claims administrators and utilization review organizations (UROs) are subject to UR investigation and penalties. Claims administrators are subject to what's known as "routine investigations" once every five years. These routine investigations are conducted as part of the existing audits done under Labor Code section 129. UROs are subject to routine investigations once every three years.
If the claims administrator or URO has failed a previous routine investigation, DWC can return for what's called a "target investigation." The DWC can also conduct a target investigation based on a credible complaint. Credible complaints are provided to the claims administrator for their response prior to an investigation.
During an investigation, a random sample of requests for authorization taken from the three-month calendar period prior to the commencement of the investigation, along with additional records that may be needed, is reviewed. Claims administrators and UROs receive advance notice that they have been selected for investigation. After producing the information called for about the requests for authorization received during the specified time frame, the claims administrators and UROs receive a notice at least 14 days before the investigation begins. The investigation of claims administrators occurs at the adjusting location, while the URO provides copies of all requested documents to the DWC. Once the investigation has concluded, a final investigation report (which includes a performance rating) is provided to the investigation subject.
The final investigation reports and performance ratings are posted below. Claims administrators with questions about UR should review the UR FAQ page for more information
UR investigation results for claims administrators 2008
- Adventist Health System West
- ALPHA Fund
- American Commercial Claims Administrators
- American Professional Risk Services, Inc.
- City of Modesto
- City of Torrance
- Contra Costa County Schools Insurance Group - Pleasant Hill
- JT2 Integrated Resources
- Northern CA Special Districts Insurance Authority
- RICOMP Claims Management Corporation
- Sedgwick Claims Management Services - Pasadena
- Sedgwick Claims Management Services - Van Nuys
- Sentry Insurance/ Parker Services
- State Compensation Insurance Fund - Fairfield
- State Compensation Insurance Fund Risk Management - San Francisco
- USS-POSCO Industries
- Zenith Insurance Company
UR investigation results for claims administrators 2007
- Pacific Gas & Electric Company; RehabWest, Inc.
- Republic Indemnity Company - San Diego
- Sedgwick Claims Management - Roseville
- Sedgwick Claims Management Services - Oakland
- State Compensation Insurance Fund - Oxnard
- Tri Star Risk Management - San Diego
September 2008