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Office of Self Insurance Plans (OSIP)

OSIP Audit Unit

TOP TEN
The 10 Most Common Issues Identified During an OSIP Audit

  1. Not identifying all issues on a claim and the associated probable future cost, indemnity and/or medical, over the life of the claim based on the facts of the case. 8CCR§15300

  2. Failing to annually review medical treatment costs and reserve adequacy when the injured worker has a lifetime medical award. Not adjusting reserves upon receipt of relevant information that affects the valuation of the claim. 8CCR§15300(g)

  3. For MMI/P&S status claims – Not adjusting reserves to reflect the average annual medical treatment costs based on the past three years (or less if it has been less than three years since the injured worker has reached an MMI/P&S status). 8CCR§15300(b)(4)

  4. For non MMI/P&S claims – Not reserving for the life of the claim. 8CCR§15300(b)(3)

  5. Using the wrong life expectancy table when calculating estimates of future liability. 8CCR§15300(b)(7), 8CCR§15300(b)(9)

  6. Failing to reserve for the higher permanent disability rating unless there is sufficient factual evidence to support a lower rating. 8CCR§15300(b)(2) and lowering permanent disability due to apportionment without basis or facts to support it, 8CCR§15300(b)(8)

  7. Inaccurately reporting excess insurance information.

  8. Allowing the self-insured employer to control estimates of future liability. 8CCR§15452

  9. Failing to determine the outstanding lien and unresolved unpaid medical provider balances and the expected cost of resolution based on the facts of the case. 8CCR§15300(b)(1)

  10. Prematurely closing claims with lifetime future medical benefits due. 8CCR§15400.2(a)

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