Summary of changes - Claims Management Audit Manual and appendices
Claims Management Audit Manual | ||
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Reference | Update | Comment |
Section 2 ‘Audits conducted by SIRA’ and Section 3 ‘Insurer self- audits’ | Modification | Increased clarity around processes relating to audits conducted by the self-insurer and those conducted by SIRA. Previously the manual combined the two which could lead to some confusion where there are differences in process. |
3.1 When is an audit required? | Addition | In addition to the requirement for a self-audit to be conducted at least annually, the statement that SIRA may require a further audit to be conducted in the same 12-month period has been added. |
3.5.2 Roles and responsibilities | Modification | Strengthening of wording from “should not” to “audit team cannot audit claim records if they have been involved in any aspects of the management of the claim”. |
3.6 Audit planning and timeline | Modification | SIRA will provide, along with an audit sample, confirmation of the date range of the sample and the audit period to be reviewed. This is aimed at increasing clarity in the process. |
3.7 Audit period | Modification | If a remediation plan was required following a previous audit, the period to be audited will commence 3 months from the conclusion of the previous audit (9 months rather than 12 months). This will allow some time for improvement activities and allow the subsequent audit to assess the impact of the remediation activities. |
3.8 Audit sample size and selection | Modification | Number of claims to be audited is determined by the number of claims with claims management activity (excluding notification of injury records) in the preceding 12 months of data available. Clarification that audit sample will be from pool of claims with claims management activity in the audit period (excluding notification of injury records). |
3.9 SIRA self-audit resources | Addition | Clarification the audit guide is not an exhaustive list of requirements and an auditor should apply their own knowledge and expertise to determine whether sufficient evidence to indicate compliance. Further if there is any conflict between the Guide and relevant legislation, the legislation takes precedence. A Single point of contact with SIRA for self-audit related enquiries for insurers and auditors has been added as [email protected]. SIRA will establish regular self-audit forums advertised via SIRA Bulletins. The purpose of these is to address any issues or clarify points related to the self-audit process and documentation. These will be open to auditors and insurers alike. |
3.10 Remediation plans | Addition | Inclusion to ensure remediation plans follow issued insurer guidance on remediation plans (attached as Appendix E). |
Appendix A – SIRA Self-Audit Tool & Appendix B – SIRA Self-Audit Guide | ||
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Reference | Update | Comment |
1.2 Employer initial Communication | Modification | Component modified from compliance to case management practice. Removal of worker initial communication in component. Standard of Practice 33/34 included as a reference. |
1.3 Worker initial Communication | Addition | New component classified as Case Management Practice. No change to information taken from previous criterion number 1.2. Standard of Practice 33/34 and Customer Service Conduct Principles included as references. |
1.4 Workers consent | Modification | s243 of the 1998 Act included as reference. |
2.1 Initial injury management planning | Modification | Component modified from compliance to case management practice. Inclusion of risk factor identification across multi domains in auditing principles and considerations. Standards of Practice 33 & 34 included as a reference. |
2.2 Subsequent injury management planning | Modification | Component modified from compliance to case management practice. Inclusion of risk factor identification across multi domains in auditing principles and considerations. Standards of Practice 33 & 34 included as a reference. |
3.1 Promoting recovery at work | Modification | Component modified from compliance to case management practice. Standards of Practice 33 & 34 included as a reference. |
3.3 Claim handover | Modification | Referenced required insurer actions as per Injury Management Program in auditing principle and consideration. |
6.1 Initial PIAWE calculation | Modification | Auditing principle and consideration to including information to obtain pay information from employer to calculate worker PIAWE. Removal of reference to interim PIAWE calculation. Clause 8N of the Workers Compensation Regulation 2016 to be included in references. |
6.2 Interim PIAWE calculation | Addition | New component classified as compliance Auditing principle and consideration includes information previously in 6.1. This now also includes information regarding timeframes to request further information from employer within five working days. Further inclusion that the insurer must make payment within 14 days after making calculations if the new PIAWE is more than the interim PIAWE. Clause 8N of the Workers Compensation Regulation 2016 to be included in references. |
6.4 Certificate of Capacity | Modification | Modification of previous 6.3 (due to inclusion of new 6.1 criterion). Auditing principle and consideration includes information where a certificate of capacity is not provided and the actions an insurer can take. |
8.3 Service and treatment provider approvals | Modification | Auditing principle and consideration includes information referencing actions if pre-approval not required. S279 Worker’s Compensation Act 1998 included in references. |
Appendix D – SIRA Self-Audit Remediation Plan Template | ||
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Reference | Update | Comment |
1. Remediation plan process | Modification | Update of template and process to be aligned with insurer guidance on remediation plans (Appendix E). |