• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Print this page
You are here: Home . wc . pbo . icpbo

Performance Based Oversight (PBO) - Insurance Carrier


Insurance Carrier 2018 PBO Assessment Methodology

Downloads:

2018 Insurance Carrier Assessment Methodology Paper (Nov 2017 pdf)

Selection Criteria | Weighted Measures | Data Timeframe | Data Source | Tier Structure and Placement Methodology

Insurance Carrier Selection Criteria

The insurance carriers selected for the 2018 PBO assessment are selected based on the following:

  • The volume of initial payment of Temporary Income Benefit transactions between January 1, 2017 and June 30, 2017
  • Initial Payment of TIBs Volume
    • Lowest number of initial payments: 20

Weighted Measures

The selected insurance carriers will be assessed on the following measures for the 2018 PBO assessment:

  1. 40% weight - Timely payment of initial Temporary Income Benefits by the insurance carrier
  2. 30% weight - Timely processing of initial medical bills by the insurance carrier
  3. 10% weight - Timely processing of request for reconsideration medical bills by the insurance carrier
  4. 10% weight - Timely submission of Initial Payment data via Electronic Data Interchange (EDI)
  5. 10% weight - Timely submission of Medical Bill Processing data via EDI

Data Timeframe used for 2018 Assessment

For the insurance carriers the data timeframe used to assess performance of the above measures will be:

All insurance carrier measures: January 1, 2018 through June 30, 2018

Data Sources

The data sources used to assess performance of the above measures will come from the claim and medical data submitted electronically via EDI to the TDI-DWC.

Tier Structure and Placement Methodology

The TDI-DWC will have three regulatory tiers that distinguish among poor, average, and high performers in the system. Those assessed are deemed to have an impact on the system due to their volume of filings or initiation of benefit payments. The TDI-DWC is not asserting that high volume has a negative impact on the system. Those insurance carriers who are not assessed due to low volume are not absolved from regulatory duties or regulatory oversight when necessary.

In placing the selected entities into regulatory tiers, the TDI-DWC will conduct several steps to place each insurance carrier into an overall tier. The first step is to calculate the performance score (percentage) for each measure. Next, the performance score for each measure will be multiplied by the assigned weight value – the value is rounded up. This calculation of two percentages will then be multiplied by 100 to obtain a weighted value – the value is rounded up. The weighted value of each measure will then be added together to calculate the final score – no rounding. The final score will identify the overall performance standard for the assessed entity. The overall performance standard is defined below.

The final scores will be placed into three regulatory tiers based on pre-determined performance standards that distinguish among poor, average, and high performers in the system.

The performance standards are:

High Tier: 95 or greater
Average Tier: 80.00 through 94.99
Poor Tier: 79.99 or less



For more information, contact:

Last updated: 11/03/2017

Contact Information and Other Helpful Links