chapter 3 oag workers' compensation board: claims management · recommendation 3.4 the...

45Independent Auditor’s Report • • • Office of the Auditor General • • • May 2019

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Internal Appeals

• Ourtestingshowedthatappealswereevaluatedinlinewithpolicies• Almost half of our tests showed that employers inappropriately received sensitive private medical

informationthatwasnotclaimrelated• Severalworkers’appealswerenotprocessedinlinewiththeWCB’s90-daytarget• Ourtestingshowedthatworkers’appeals,onaverage,took50businessdaystoassign• Almosthalfoftheapprovedappealstestedtookmorethan2weeksfortheimplementationprocessto

begin

• Ourtestingshowedthatdecisionsonworkers’claimsmetpoliciesandweresupported• Overhalfthetime,ourtestingshowedworkersdidnotreceivewrittenclaimdecisionswithin30days• Halfofworkerstesteddidnotreceivecommunicationaboutthecalculationoftheirbenefits• Workers’ complaintsmay not be addressed properly due to significant deficiencies in the complaint

process

Claims and Benefits Administration

Overall Conclusions• TheWorkers’CompensationBoardgenerallymanagesworkplaceinjuryclaimseffectively,incompliance

withpoliciesandprocedures.However,weidentified12recommendationsforimprovement.• Weaknessesidentifiedincludenotbeingtimelyandinadequatecomplaintandprivacyprocesses.

Chapter3Workers'CompensationBoard:ClaimsManagement

Return-to-Work Planning

• WCBmanagedworkersreturntoworkonatimelyandappropriatebasisinaccordancewithpolicies• Most files tested needed improved documentation to support effective monitoring and to prevent

potentialerrors

Quality Assurance and Staff Development

• Quarterlymanagerfilereviewswerenotdoneasrequiredforhalfofcaseworkerstested• PoortrackingoftrainingrecordsmeantitwasunclearifWCBworkerstooktheirrequiredtraining

• 65%ofWCBemployeestestedhadnorecordtoshowcrisispreventiontraininghadbeentaken• Performancemanagementprocesseswerenotalwayscompleted

• 30%oftestedemployeesdidnothaveasix-monthperformancereviewin2017

Service Provider Contracts

• Theservicecontractforcomplexsprainandstraininjurieswasawardedinlinewithprocurementpolicy• WCBmonitorsservicestoworkersandevaluatesresultsagainstperformancetargets• WCBcouldimproveitsrequiredquarterlyreportingmeetingprocess• Serviceswerereceived,andpaymentsmade,inaccordancewithcontractterms• Reportedincidentswereinvestigatedwithactionstakenasrequired

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Workers' Compensation Board: Claims Management

RecommendationsataGlance

Recommendation 3.1TheWorkers’CompensationBoardshouldensurethattheyareconsistentlycommunicatingwithinjuredworkersonatimelybasisandprovidingallrelevantdetailsregardingdecisions,includinghowbenefitswerecalculated.

Recommendation 3.2The Workers' Compensation Board should review performance standards for requestingpermanent impairment benefit assessments and implement processes to ensure thesestandardsaremonitored.

Recommendation 3.3TheWorkers’CompensationBoardshouldimprovethecomplaintresolutionprocess,includingimplementingpropersegregationofduties,andthecreationofaformalcomplaintlogthatincludesallcomplaintsreceived,aswellasdocumentingtheactionstaken,bothtomakeaninitialdecisiononthevalidityofthecomplaintandtoensureservicedeliverystandardsaremet.Managementshouldalsoimplementaqualityreviewprocessovercomplaints.

Recommendation 3.4TheWorkers’CompensationBoardshouldensurethatboththeinjuredworkerandemployeraccepttheinitialaccidentreport.

Recommendation 3.5TheWorkers’CompensationBoardshouldreviewbenefitpaymentprocessesandimplementcontrolstoensurethatonlyauthorizedadditionsandchangestobenefitshappen,andthatsupportingdocumentationforallpaymentsisonfile.

Recommendation 3.6TheWorkers’CompensationBoardshouldreviewcurrentpracticesandimplementanupdatedprocess, including review and document retention standards, for vetting workers' files toensureallsensitiveunrelatedinformationisremovedbeforebeingsenttoathirdparty.

Recommendation 3.7TheWorkers’CompensationBoardshouldestablishprocessestoensurethatappealdecisionsaremadewithin targetedtimeframes,casemanagement is clearlydocumented tosupportreasonableactionsweretakentoresolvethefileinanefficientmanner,andproperoversightexists.

Recommendation 3.8TheWorker’sCompensationBoardshouldestablishimplementationandmonitoringprocessestoensurethatallappealdecisionsareimplementedinatimelyandefficientmanner.

Recommendation 3.9The Workers’ Compensation Board should ensure the return-to-work case managementprocess isaccuratelydocumentedandtracksthestepstakentoreturntheworkertowork,includinganychangesmadeduringtheprocess.

Recommendation 3.10TheWorkers’CompensationBoardshouldensurethatfilereviewsarecompletedasrequired,anddocumentactionstakentoresolveissuesidentified.

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Recommendation 3.11TheWorkers’CompensationBoardshouldimplementasystemtomonitorthecompletionoftrainingbystaff,includingnotificationforwhentrainingupdatesarerequired.

Recommendation 3.12TheWorkers’CompensationBoardshouldensurethatallpartsoftheperformanceplanningandassessmentprocessarecompletedanddocumented.

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IndependentAuditor’sReport•••OfficeoftheAuditorGeneral•••May2019

Return-to-WorkPlanning

3.1 In December 2018, we released an independent assurance report ongovernance practices and plans for the long-term sustainability of theWorkers’CompensationBoard.Thisreportcontinuesourlookatworkplaceinjuryinsuranceandexaminesoperationalperformancearoundclaimsandbenefitsadministration,internalappealprocesses,return-to-workprograms,andcontractmanagement.

3.2 BackgroundinformationontheWorkers’CompensationBoardisavailableinAppendixII.

ClaimsandBenefitsAdministration

Workers’ Compensation Board follows policies and procedures when making claims decisions

3.3 Whenaworkerexperiencesaninjuryonthejob,employersarerequiredtonotify theWorkers’CompensationBoardwithinfivebusinessdays.Uponreceipt,theWorkers’CompensationBoardassignstheclaimtoacaseworkerbasedonthenatureoftheinjuryandrisklevel.In75%ofcases,adecisionregarding initial approval of compensation is expected to bemadewithintwoweeksofwhentheclaimwasregistered.Theremaining25%aremorecomplexcaseswhichrequireadditionaltimetoadequatelyreviewand,whennecessary,obtainadditionalinformation.

3.4 Overall, we found that the Workers’ Compensation Board followed itspoliciesandprocedureswhenforminginitialdecisionsregardingtheawardof compensation in the 30 claims decisions tested.While claims decision-makingofteninvolvesprofessionaljudgment,wefoundthatdecisionswerereasonable,consistentwithinformationinthefile,andsufficientlysupported.

3.5 In instanceswhenclaimscontainedconflicting information,wefoundthatcaseworkers took reasonable action and consulted with internal medicaladvisorsasappropriate.

3 Workers'CompensationBoard:ClaimsManagement

InjuryAccidentReporting(Employer)

AssignedtoCaseWorker

AllRequiredInformationAvailable?

DecisionBenefits

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Workers’ Compensation Board did not complete written decisions on a timely basis

3.6 Whenaclaimisdenied,theworkerisfirstinformedofthedecisiongenerallybyphone,andthenaformalwrittendecisionexplainingthefullrationaleisprepared.Eithertheinjuredworkerortheemployercanrequestthiswrittendecisionafteranydecisionisreached.Theinternalpolicystatesthiswrittendecision should be completed within 2 days of the decision being made;however,managementstatedthat30daysisusedinpractice.

3.7 Thewrittendecisionmustbepreparedpriortoeithertheinjuredworkeroremployerlaunchinganappealofaclaimdecision,sohavingitcompletedinatimelymannerisakeystepintheprocess.ItisimportantthattheWorkers’CompensationBoarddetermineandconsistentlydefinetheexpectedlengthoftimetopreparethesedecisions,soeveryoneinvolvedinthesystemknowswhattoexpect.

3.8 Ofthe30claimsexamined,writtendecisionswererequiredin8instances.Oftheeight,nonewerepreparedwithin2days,andonlythreewerepreparedwithin30days.Theremainingfivewerepreparedfrombetween38and160days.Thismeans injuredworkersdidnotget the informationtheyneededtounderstandthedecisionprocessandtheirabilitytobeginanappealwassignificantlydelayed.

Workers’ Compensation Board did not consistently communicate how benefits were calculated

3.9 CompensationawardedtoreplacelostwagesduetoaninjuryiscalculatedbasedonaformulasetoutintheWorkers’CompensationAct.All30claimswe examined awarded, at aminimum, short-term compensation; however,halftheworkerswerenotissuedaletterdetailinghowthecompensationwascalculated.Ifaninjuredworkerdoesnothavethesedetails,itisverydifficultforthemtoknowiftheyarebeingtreatedfairlyandreceivingwhattheyareentitledto.

Recommendation 3.1The Workers’ Compensation Board should ensure that they are consistentlycommunicatingwithinjuredworkersonatimelybasisandprovidingallrelevantdetailsregardingdecisions,includinghowbenefitswerecalculated.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. In 2018 the WCB implemented a new service advancement process to ensure case workers are communicating with workers in a timely manner. In Guidewire this will be an automatic activity required to complete, or it will be escalated to the manager. With Guidewire, the WCB will also update letters to provide clarity on how benefits are calculated. The WCB has also implemented a tracking process for decisions and appeals to ensure timely claim decisions and appeal decision implementation.

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Workers’ Compensation Board did not process permanent impairment benefits in a timely manner

3.10 Injuredworkerswhosufferan injurywith lasting impactcouldbeeligiblefor a permanent impairment benefit, which is calculated separately fromearningsreplacementbenefits.Onceaninjuredworkerreachesalevelwherenofurtherimprovementintheirconditionisexpected,theworkerisreferredto a medical professional who conducts an assessment to determine if apermanent impairment exists and the degree of impairment. This is thenfactoredintothebenefitcalculation.

3.11 There is no clear performance expectation regarding timelines for thecaseworkertorequestapermanentimpairmentassessment.Thecaseworkerisresponsibletoconsultwiththemedicaladvisortodetermineiftheworkerhasreachedtheirmaximumimprovementandthentorequestanassessment.

3.12 We examined 20 claims which were awarded a permanent impairmentbenefit and found that 9werenot issued in a timelymanner; assessmentsweredelayedfromtwomonthstoayear.

• Fivedidnothaveassessmentsrequestedinatimelymanneroncethemedicaladvisorconfirmedmaximumrecovery.

• Fourwerenotreferred to themedicaladvisorforconfirmationinatimelymanner,ifatall.

3.13 Permanentimpairmentbenefitscannotbecalculateduntiltheassessmentiscompleted.Therefore,notconductingassessmentsinatimelymannerresultsinunnecessarydelaystotheinjuredworkerreceivingcompensationtheyareentitledto.

3.14 Wefound4of19caseswerenotcalculatedinatimelymanner,evenoncethenecessarymedicalassessmentsandinformationwereprovided. Whilemost cases tookanaverageof9days, these four cases ranged from38 to185additionaldaystofinalizethecalculations,addingfurtherdelayfortheinjuredworker.

Recommendation 3.2The Workers' Compensation Board should review performance standards forrequestingpermanentimpairmentbenefitassessmentsandimplementprocessestoensurethesestandardsaremonitored.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. Over the next 12 months the WCB will explore best practice for requesting permanent impairment assessments. The new Guidewire system will allow for an activity to be added for case workers once the assessment has been added to the file to ensure benefits are implemented in a timely manner.

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Significant deficiencies noted with the Workers’ Compensation Board complaint process

3.15 TheClientRelationsOfficerisresponsiblefortheentirecomplaintprocess,fromreceiving the initial intakebyphone,email,or inperson, through tothefinalinvestigation.Thereisnoreviewbymanagementoranalternativequalitycontrolprocessinplaceatanystage.Wewerethereforeunabletoobtainanyassurancethatrecordsincludedallcomplaintsreceived.

3.16 Communicationsreceivedareclassifiedaseitheraninquiryoracomplaint.A complaint is considered a formal expression of dissatisfaction with arequestfortheproblemtoberesolved.Thereisnoformalprocesstofileacomplaint,suchastheuseofastandardform.Therefore,itisreliantontheClientRelationsOfficer’sinterpretationofwhetheracommunicationshouldbeconsideredacomplaint,asopposedtoaninquirywhichdoesnotrequireextensiveinvestigation.

3.17 Onceclassifiedasacomplaint,theClientRelationsOfficerdecideswhetherit isvalid. Ifdetermined tobenotvalid,norecordof the investigation isretained.Becauseofthis,wecouldnotassesswhetherthedecisiontodeemacomplaintasnotvalidwasappropriate.

3.18 Inexaminingasampleoftencomplaintfileswhichwerefoundtobevalid,andthereforeinvestigatedfurther,wefoundthatreasonableactionwastakenbasedonthenatureofthecomplaint.However,actionwasnotalwaystimely,and in several instances, information to support that the complaint wasresolvedwasnotmaintained in thecomplaintfile. Instead, itwas locatedbyreviewingcorrespondenceintheworker'sclaimfile.Thelackofpropersupportmakesreviewandoversightofthisprocessdifficult.

3.19 Many of the complaints received relate to timeliness and communicationchallengeswithcaseworkers. Thesetypesofconcernsareconsistentwiththeissuesidentifiedthroughoutourauditandemphasizetheimportanceofaneffectivecomplaint resolutionprocess.Basedon theexistingprocessesin place, there is a high risk that not all complaints are documented andadequatelyaddressed,andthereisnowaytoconfirmthis.

Recommendation 3.3TheWorkers’CompensationBoardshouldimprovethecomplaintresolutionprocess,includingimplementingpropersegregationofduties,andthecreationofaformalcomplaint log that includes all complaints received, aswell asdocumenting theactionstaken,bothtomakeaninitialdecisiononthevalidityofthecomplaintandtoensureservicedeliverystandardsaremet.Managementshouldalsoimplementaqualityreviewprocessovercomplaints.

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Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. Over the next 12-18 months we will undertake a best practice review of complaint resolution processes and revise our program and processes based on that review.

Workers’ Compensation Board did not ensure injured workers sign accident reports

3.20 Whenaworker is injuredon the jobandeithermisses time fromworkormedicalattentionisneeded,employersarerequiredtouseaninjuryreportformtonotifytheWorkers’CompensationBoard.Theformindicatesthatboththeemployerandworkermustsignthereport;however,morethanhalfof the accident reports we examined did not contain the signature of theinjuredworker.

3.21 Itisimportantthattheworker’ssignatureispresenttoshowtheyagreethattheinformationsubmitted,whichformstheinitialbasisfortheclaim,isaccurateand complete. It also provides consent that the Workers’ CompensationBoardmayneedinordertoobtainanddistributeinformationfromMSIandMedavieBlueCrosstoprocesstheclaim.

Recommendation 3.4TheWorkers’CompensationBoardshouldensurethatboththeinjuredworkerandemployeraccepttheinitialaccidentreport.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees that workers should have access to the information on their workplace injury submitted by their employer, and they should understand that the WCB may need to obtain and process information from MSI and Medavie Blue Cross to process their claim. Increasingly, accident reports are submitted electronically by the employer without employer or worker signatures. Over the next 12-24 months the WCB will explore options on how to leverage the new Guidewire system to ensure workers have this information. In the meantime, when the worker has not signed the accident report, the case worker, as part of their initial contact, will read the description of accident to the worker to ensure it is accurate and complete and explain the ability of WCB to obtain medical information needed in relation to the injury from any current or previous health care person.

Workers’ Compensation Board has control deficiencies in payment authority

3.22 Allcaseworkersat theWorkers’CompensationBoardcanestablishand/ormodifycompensationbenefitsforlostwagesforanyinjuredworker.Thereis no quality review or other monitoring process in place to ensure onlyauthorizedadditionsandchangesaremade. Duringdetailedexamination,we determined that initial rate calculations for short-term claims wereappropriatelysupported.16ofthe30claimshadadditionaladjustmentsandallwereappropriatelysupportedwithanewratesheet.

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3.23 We did not identify any instances of unauthorized additions or changes.However,withnoqualityrevieworothermonitoringprocess,benefitscouldbe awarded orwithheld from aworkerwithout detection by theWorkers’CompensationBoardandtherefore,shouldbeaddressed.

3.24 Whileratesheetsandauthorizationswereinplaceforallbenefitpayments,weidentifiedseveralconcernsincluding:

• threehadnosupportingdocumentationsowecouldnotconfirmtheaccuracyofthebenefitcalculation

• twocontainedminormathematicalorinputerrorsresultinginunderoroverpaymentstotheinjuredworkeroflessthan$100intotal

3.25 BenefitsarespecificallysetoutintheActanditisimperativethatthesearecalculatedcorrectlytoensurethatworkersreceivewhattheyareentitledto.

Recommendation 3.5TheWorkers’CompensationBoardshouldreviewbenefitpaymentprocessesandimplementcontrolstoensurethatonlyauthorizedadditionsandchangestobenefitshappen,andthatsupportingdocumentationforallpaymentsisonfile.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. With the implementation of the Guidewire system, all payments and history is recorded in the claim file and cannot be paid without the record. Over the next 12-24 months the WCB will review the current benefit calculation and payment processes and research best practice to ensure we have appropriate controls in place. Currently long-term benefits are calculated by a quality assurance position for the case worker and then authorized by the case worker.

InternalAppeals

3.26 Internal appeals are the first step in the process if a worker or employerdisagreeswith a claim decision. 1,450 notice of appealswere received bytheWorkers’CompensationBoardin2016,and1,418in2017.Approximately,15%ofinternalappealsresultintheappealbeingapproved,atleastinpart.

3.27 WefoundtheWorkers’CompensationBoardgenerallyfolloweditsprocess.Inall20internalappealswetested,bothpartieswereappropriatelynotifiedof theappeal andprovided theopportunity tomakea submission. Whensubmissions, and other documents requested by the hearing officer werereceived, the appeal was reviewed in full and a decision was made. Awrittendecisionwaspreparedforallinternalappealstested,anditexplainedthe reasoningof thehearingofficer, including references to legislation, asrequired.

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3.28 Although the appropriate process to come to a decisionwas followed,wewereconcernedtofindprivacybreaches,andmoreissuesaroundtimeliness,which could continue to cause delays for some injuredworkers to receiveproperbenefits.

Privacy breaches occurred in files provided to employers during the internal appeal process

3.29 During the internal appeal process, an employer may request access toinformationinaworker’sclaimfile.DocumentsprovidedaretobelimitedtoinformationrelevanttotheBoard’sdecisionandredactedasnecessarytoremove irrelevant information. Ofconcern, is the sharingof anymedicalinformationunrelatedtotheinjuryormedicalissueinquestion.

3.30 Wetested20filesthatweresenttoemployersandfound9includedsensitiveinformationthatwasnotclearlyrelevanttotheclaimanddecision.Itincluded,forexample,medicationstheworkerwastakingandinformationoncurrentandpastillnessesandinjuries.

3.31 Insixoftheninefiles,sensitiveinformationwasredactedinsomeplacesinthefile,butnotinall.Thisclearlyshowedthatthestaffmemberwhoperformedthevettingbelievedtheinformationtobesensitiveandunnecessarytothedecision,buttheyfailedtoredactitinallinstances.

3.32 Workers’CompensationBoardpolicyrequiresthatamanagerreviewallfilescontainingsensitiveinformationpriortothefilebeingsenttotheemployer;however,nomanagerreviewedthreeoftheninefiles.Evenwhenamanagerreviewedafile,privacybreachesstilloccurred.

3.33 Vettedfilesaredestroyedoneyearaftertheyaresenttotheemployer.Thisprocessisnotdocumentedinpolicy.Provincialdocumentretentionpoliciesrequiresimilarrecordsbekeptforalongerperiod. Forexample,redactedFOIPOPcasedocumentsmustberetainedforatleastnineyears.DuetotheBoard’sprocess,wewereonly able to select claimfiles sent to employerswithintheyearpriortoourtesting.

3.34 Disclosure of an injured worker’s medical records is a high-risk area, asunauthorized release of information not related to the claim decisioncouldhavea significant andpotentiallydetrimental impact for theworker.Processesinplacetoreleasethesetypesofsensitivedocumentsmustreflecttheimportanceofaworker’sprivacyandensureonlynecessaryinformationisprovidedtoemployers.

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Recommendation 3.6TheWorkers’CompensationBoardshouldreviewcurrentpracticesandimplementanupdatedprocess,includingreviewanddocumentretentionstandards,forvettingworkers'filestoensureallsensitiveunrelatedinformationisremovedbeforebeingsenttoathirdparty.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. Over the next 12-24 months the WCB will explore best practice options for document review, retention and vetting sensitive information removal.

Decisions on internal appeals often exceed the targeted timeframe

3.35 Sixof20appeals testeddidnotmeet theoverall timelineestablished,andtherewasnosupporttojustifywhythetargetwasexceededinfourcases.

3.36 TheWorkers’CompensationBoardhasatargetof90daystocompleteanappealfromthedateanoticeofappealisreceivedtothedecisiondate.Inthe4of20appealswithdelaysthatdidnotappearreasonable,decisionsweremadefrombetween140to458businessdays.Managementstatedalltargetsarebasedonbusinessdays.Thisisnotclearlydefinedindocumentationandthisexpectationshouldbeclarifiedforstakeholders.

3.37 When aworkerfiles an appeal theyhave alreadygone through the initialclaimprocess to obtain awritten decision, and as discussed above,manyhaveexperienceddelaysinthatprocess.Itisthereforeessentialthatappealdecisionsberenderedinatimelymanner.

Case management and monitoring of internal appeals is not adequate

3.38 There is no standardized process to indicatewhat specific documentationshouldbeineachclaimfile,andnoclearexpectationsofwhatstepsintheprocesshearingofficersshoulddocument.Asaresult,itisdifficulttotrackthestatusofappealsasitisnecessarytoreadeachdocumentonfile,one-by-one, to follow theprocess. This is a time-consumingpracticeandmakesefficientmonitoringbymanagementdifficult.

3.39 Wealsonotedalackofdirectiononwhattodowhendelaysarerequestedbyaworker,employer, representative,orWorkers’CompensationBoardstaff.Adelayresultsintheappealtakinglongertobedecidedandcannegativelyimpact theworkeror employer throughdelaying the receipt ofbenefitsorpayingincreasedfees.Wenotedtwoexamplesofthisoccurringinthefileswetested.

• Foronefiletested,theappealdidnotrequireadditionalinformation;however,thehearingofficerplacedadelayrequestonthefilebefore

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schedulingahearing.Neitherthereasonforthedelay,northeexpectedtimeframeforthehearing,wasdocumented.

• In theotherexample,variouspiecesofadditional information, thatdidnotappeartoberequestedbythehearingofficer,wereprovidedoveranextendedtimeperiodbytheemployer.Thisresultedinthedecisiontaking308businessdaystomake,withnoexplanationforwhytheinformationwasrequired,orevendeadlinesfortheemployertoprovidetheadditionalinformation.

3.40 Eachweek,themanagerworkswiththehearingofficerstoprioritizefiles,butthereisnopolicydefininghowthisshouldbedone.Thecurrentprocedureonly states that the hearing officerswill identify any priority appeals. Amoredescriptivepolicywouldhelpensurefilesareconsistentlyprioritized.

3.41 Wefoundthereweresignificantdelaysinassigningfilestoahearingofficertobegintheappealprocess.Forthe20appealstested,wefoundtheaveragetimeittookafiletobeassignedtoahearingofficerwas50businessdays,more thanhalf the90-day timeframe inwhichanappeal is tobedecided.Thereisnojustificationforfilesnottobeassignedtoahearingofficerinatimelymanner.Assigningfilesinatimelymannerallowshearingofficerstoperformtheinitialreviewtorequestadditionaldocuments,ifrequired.

Recommendation 3.7The Workers’ Compensation Board should establish processes to ensure thatappealdecisionsaremadewithintargetedtimeframes,casemanagementisclearlydocumented to support reasonable actions were taken to resolve the file in anefficientmanner,andproperoversightexists.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. Over the next 12-24 months the WCB will review the current process and research best practice to ensure an efficient and timely internal appeals process within the policy timelines, including developing standards for documentation and monitoring of performance to standards. To improve timeliness of appeal decisions, the WCB has hired an additional Hearing Officer.

No process for implementing internal appeal decisions

3.42 Thereisnoformalwrittenprocedurespecifyingtheprocessortimelinestoimplementtheresultsofanyappeal,whetherinternalorfromtheWorkers’CompensationAppealsTribunal. TheAppealsTribunal isan independentoffice from theWorkers’CompensationBoard and is the next step in theprocessifsomeonedisagreeswiththeinternalappealdecision.

3.43 Managementtoldustheyuseatargetoftwoweekstobeginimplementationafter a decision is rendered, but we could not find any documentation

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indicatinghowlongitshouldtaketoimplementeachdecisionnoranythingtoshowwhoisresponsibleforimplementationortomonitorthatithappens.We found that in 5 of 10 internal appeal decisions, and 4 of 10Workers’CompensationAppealsTribunaldecisions,implementationbeganmorethantwoweeksafterthedecision.

3.44 The Workers' Compensation Board should use a centralized monitoringapproach to ensure that appeal decisions are implemented. Withoutmonitoring processes, theremay be further delays to a worker obtainingbenefits.

Recommendation 3.8TheWorker’sCompensationBoardshouldestablishimplementationandmonitoringprocesses to ensure that all appeal decisions are implemented in a timely andefficientmanner.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. We have implemented a process to centralize the review of appeal decisions, document and monitor implementation. With Guidewire, an activity will be added to the file for the case worker to ensure the appeal is implemented. Notification will be escalated to the manager if the activity is not completed.

Medical review process is not in line with Workers’ Compensation Act

3.45 TheWorkers’ Compensation Act includes reference to aMedical ReviewCommissionfromwhommedicalopinionscouldberequestedbytheWorkers’CompensationBoard.ThispanelofmedicalexpertswouldbeappointedbytheMinisterofLabour andAdvancedEducation,but thepanelwasneverestablished.

3.46 The 2002 Dorsey Report stated that the committee found no support toestablish theMedicalReviewCommissionandthecurrentappealsystemswereworkingwell.ManagementatLabourandAdvancedEducationstatedthat thisviewwaswidely acceptedbasedon thegeneral response to takeactionontheDorseyReport,althoughtheMedicalReviewCommissionwasnotexplicitlyaddressed.

3.47 TheActhasseenseveralchangessincetheDorseyreportin2002;however,thesectionregardingtheMedicalReviewCommissionremainsinlegislation.TheActandcurrentpracticeshouldbeconsistentsothateveryoneunderstandswhattoexpect.

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Return-to-WorkPlanning

Approach to return-to-work is timely and appropriate

3.48 Guidanceonreturn-to-workscenariosisprovidedtocaseworkersthroughacasemanagementtoolkit.Wefoundthereisanappropriatelevelofguidanceprovided tocaseworkers regardingreturn-to-workplanningand, ifneeded,caseworkershavechannelsavailabletothemtoseekadditionaldirection.

3.49 Inall30oftheclaimswereviewed,wefoundthatthecaseworkermanagedthe worker’s return-to-work process in a timely and appropriate manner,followingthedefinedprocessforcoordinatingtheirreturntowork.All30filesincludedinitialmedicalreports,regularmedicalupdates,andevidenceof meetings held with relevant parties when progress towards a worker'sreturntoworkdidnotoccurasanticipated.

Return-to-work plans are not clearly documented

3.50 Only5ofthe30claimstestedhadthereturn-to-workapproachadequatelydocumentedontheactionplanwhichissupposedtobethecentrallocationfor the return-to-work plan. All claim files contained correspondencediscussingthereturn-to-workprocessandmedicaldocumentationtosupporttheapproachtobeused;however,thisinformationandstatusupdateswerespreadthroughouttheworker’sfileandwerenotclearlyoutlinedontheactionplan.

3.51 This situation is further complicated by the fact that the action plan iscurrentlyalivingdocumentthatcanbeeditedbythecaseworkeratanypoint.Thisresultsinitnotbeingreliableasahistoricalrecordofthereturn-to-workprocess.

3.52 Forexample,oneofthefieldstobedocumentedontheactionplanisthefinalreturn-to-workdate.Wefound11claimswiththereturn-to-workdatenotedontheactionplannotmatchingthereturn-to-workdatenotedintheclaimsadministrationsystem.Managementtoldusthismayhavehappenedbecausethedatewasinitiallyinput thenlaterchangedontheactionplan;however,therewasno recordof the change, therefore it is unclearwhich system isaccurate.TheclaimsadministrationsystemmustbeaccuratebecauseitisusedtoevaluateperformancetargetswhichareperiodicallyreportedtotheBoardofDirectors.

3.53 Sufficientandaccuratedocumentationofthereturn-to-workplanisimportantformonitoringandresolvingclaimsonatimelybasis.Bynotdocumentingthereturn-to-workplan,thereisariskthatcaseworkerscouldmisscertainpiecesofinformationintheprocess,resultinginalessefficientandeffectivereturntowork.

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Recommendation 3.9The Workers’ Compensation Board should ensure the return-to-work casemanagementprocessisaccuratelydocumentedandtracksthestepstakentoreturntheworkertowork,includinganychangesmadeduringtheprocess.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. Over the next 12-24 months the WCB will review the capabilities of the new Guidewire system to determine what the best approach will be to ensure accurate documentation of the return to work process.

QualityAssuranceandStaffDevelopment

File review processes are not consistently followed

3.54 In 2018, the Workers’ Compensation Board created a new file reviewspecialistrolewithresponsibilitytoreviewselectcaseworkercaseloads.Thefilereviewprocessisinplacetoprovideguidancetocaseworkersregardingthetimelyresolutionoftheiractiveclaimsandprovidefeedbacktoimproveoverallqualityofservicedelivery.Wefoundissuesaroundcompletenessandtimelinessofthereviewsdonebythefilereviewspecialist.

3.55 Managers also complete a sampleoffile reviewson each caseworker.Wefoundmanagershadnot completed thesequarterly reviews forhalfof thetencaseworkerswetested.Weencouragemanagementtoensuretheseareaddressedgoingforward,asbothreviewprocesseshaveadirectimpactonimprovingthequalityofserviceprovidedtoinjuredworkers.

Recommendation 3.10TheWorkers’CompensationBoardshouldensurethatfilereviewsarecompletedasrequired,anddocumentactionstakentoresolveissuesidentified.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with this recommendation. This was added to the WCB’s Enterprise Risk Management process last year and it is reviewed annually.

Limited to no tracking of training completion

3.56 Allnewcaseworkersarerequired tocompleteasix toeight-weektrainingprogram that consists of classroom training, self-study, eLearn training,andmeetingswith theircoachandmanager. Thoseresponsibleforhigherriskclaimsmustalsocompleteanonboardingprocessfocusedonadvancedpracticalapplicationofthetheorylearnedduringthecaseworkerprogram.

3.57 Prior to late2018, thecompletionofboth thecaseworkerprogramand theadvancedonboardingprocessweremanually trackedonpaperwhichwasthen provided to the employee to use as a reference tool. Therewere no

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records available during the audit period to determine if workers hadcompletedeitherprogramasrequired.

3.58 TheWorkers’CompensationBoard does not currently have a schedule totrackwhoneedstocompletetrainingupdates.Theyrelyontheinformationrecordedbytheemployeewhichisreviewedbymanagement.Wefoundthisinformationwasnotconsistentlycompleted.

3.59 Managementindicatedthatthehumanresourcesdepartmentisresponsibletoensurethatallorientationtrainingcoursesarecompletedandtotrackwhenemployeesneedtocompletetrainingupdates.Thisiscontrarytotheviewofthehumanresourcesdepartmentwhichindicatedthatthisistheresponsibilityofmanagement.

3.60 Internalpolicies require thatvariouscoursesbeupdatedatdifferent times,butthereisnosystemorprocesstoensurethishappens. Forexample,allemployeesarerequiredtohavecrisispreventiontrainingandupdateiteverythreeyears.Weselectedasampleof26employeesfortestingandfound17hadnorecordofhavingevercompletedthecrisispreventiontraining.Oftheremainingnineemployeeswhocompletedtheinitialtrainingorupdate,fourdidnotcompleteitonschedule.

Recommendation 3.11TheWorkers’ Compensation Board should implement a system to monitor thecompletionof trainingby staff, includingnotification forwhen trainingupdatesarerequired.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with the recommendation. We will utilize our Learning Management System for this purpose if possible, or we will resolve it through the planned implementation of a new Human Resources Information System in 2020. By policy, Managers are responsible to ensure employee training is completed and we will reinforce this message to the leadership team in 2019.

Annual and interim performance evaluations were not completed as required

3.61 Annualperformanceevaluationsofcaseworkersweredoneontime;however,not all sections of the performance planning and assessment form werecompleted.Wefoundthatonly11of24assessmentswerecompletedcorrectlyin2016andonly17of26assessmentswerecompletedcorrectlyin2017.

3.62 Part of the performance planning and assessment process is a six-monthinterim performance review. We found that only 10 of 22 assessmentsrequiringan interimreviewhadonecompleted for2016andonly 18of25assessmentsrequiringaninterimreviewfor2017hadonecompleted.

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Recommendation 3.12TheWorkers’CompensationBoardshouldensurethatallpartsoftheperformanceplanningandassessmentprocessarecompletedanddocumented.

Workers’ Compensation Board Response: The Workers’ Compensation Board agrees with the recommendation. We will update our performance planning and assessment process by the end of 2019 and work with the leadership team to ensure all elements of the performance planning and assessment tool are consistently completed and documented.

Caseworkers have required qualifications and security checks

3.63 Weselecteda sampleof 16caseworkershiredduring theauditperiodandfoundthatall16hadtherequiredqualificationsnotedontheirresumesandhadasuccessfulsecuritycheckonfile.

ServiceProviderContracts

Contracts for treatment services cover key requirements and are properly awarded

3.64 The Workers’ Compensation Board has contracts with chiropractic andphysiotherapyclinicstoproviderehabilitationservicesforinjuredworkers.Thereare three levelsof service: tier 1,2and3,which range fromsimplesprains, to more complex care cases. All credentialed service providerscan apply to provide tier 1 services, whereas since May 2016 the morecomprehensivetier2and3servicesareonlyprovidedacross theprovincethroughoneserviceprovider.

3.65 Asrequiredbypolicy, theWorkers’CompensationBoard issueda requestfor proposals to award the contract for tier 2 and 3 services. Proposalswereevaluatedbasedonestablishedcriteriaandthecontractwasawardedappropriately.

3.66 Allcontractsfortieredservicesincludecleartermsandconditions,includingfunding, performance expectations, and accountability requirements.Paymentstoserviceproviderswerewellsupported,appropriateandaccurate,andnosignificantissueswereidentified.

Tier 2/3 contract performance is monitored

3.67 As required in the tier 2/3 service contract, there are two committees inplacetomonitortheperformanceofthecontractandimproveuponservicesprovided.CommitteemembershipsconsistofrepresentativesfromboththeWorkers’CompensationBoardandtheserviceproviderandbothfunctionedasintendedtomeettheirdefinedobjectives.

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3.68 Thecontractandtier2/3serviceguidesincludeperformancemeasuresandindicatorstohelpdetermineiftheserviceproviderisachievingtheprogram'sgoals and objectives. The Workers’ Compensation Board has developedreports to monitor the service provider’s performance against these pre-determinedtargetsandtheoutcomesarereviewedanddiscussedwithseniormanagementatreportingmeetings.

3.69 The contract requires quarterly performance reportingmeetings; however,therewasnodocumentationtoprovideevidencethatthesemeetingsoccurredquarterly. Managementnoted that the reportingdashboard is available inrealtime;however,aclearlydocumentedreviewprocessshouldbeinplacefortherequiredcheck-inpointstoensurethereisevidencethatperformanceresultsarereviewed.

Workers’ Compensation Board has an incident investigation process

3.70 Aprocessisinplaceformanagingandtrackinganyincidentorinjurythattakes place while an injured worker is attending a contracted clinic fortreatment.Weexamined10incidentsandfoundtheywereallinvestigatedandappropriateactionwastaken,whenrequired,toresolvetheissuewiththeserviceprovider.

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AdditionalCommentsfromtheWorkers’CompensationBoard

Overall, we are pleased this report confirms the WCB is managing workplace injury claims effectively.

In particular, the important aspects of managing return to work for those Nova Scotians hurt on the job and health services contract management, are foundational aspects of the WCB’s contributions to this province, and we are pleased your review shows they are functioning appropriately overall.

When developing the WCB Strategic Plan 2016-2020 we recognized that workers and employers expect service improvements and your recommendations reaffirm this. We are, at this moment, implementing the biggest piece of the most extensive modernization in our history. Over time, this will bring improvements to the way we deliver service across people, process, and technology. The enhancements will begin to address many of the challenges associated with our current operations.

Your report includes many important opportunities for us to improve, particularly with regards to timeliness, complaints, documentation and some aspects of the way we handle employer access to claim file information.

We accept all of the recommendations and look forward to their implementation.

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AppendixI

ReasonableAssuranceEngagementDescriptionandConclusions

In spring 2019,we completed an independent assurance report of claimsmanagement attheWorkers’CompensationBoard.ThepurposeofthisperformanceauditwastodeterminewhethertheWorkers’CompensationBoard iseffectivelymanagingworkplace injuryclaims.The audit did not include the operations of theWorkers’ Compensation Appeals TribunalortheWorkers’AssistanceProgram.Thisisthesecondofatwo-phaseaudit,followingourreportreleasedinDecember2018thatlookedatgovernancepracticesandplanningforlong-termsustainability.

It is our role to independently express a conclusion about whether claims managementcompliesinallsignificantrespectswiththeapplicablecriteria.ManagementattheWorkers’CompensationBoardacknowledgedtheirresponsibilityforclaimsmanagement.

ThisauditwasperformedtoareasonablelevelofassuranceinaccordancewiththeCanadianStandard for Assurance Engagements (CSAE) 3001—Direct Engagements set out by theCharteredProfessionalAccountantsofCanada;andSections18and21oftheAuditorGeneralAct.

We applied the Canadian Standard on Quality Control 1 and, accordingly, maintained acomprehensive system of quality control, including documented policies and proceduresregardingcompliancewithethicalrequirements,professionalstandards,andapplicablelegalandregulatoryrequirements.

In conducting the audit work, we complied with the independence and other ethicalrequirementsoftheCodeofProfessionalConductofCharteredProfessionalAccountantsofNovaScotia,aswellasthoseoutlinedinNovaScotia’sCodeofConductforpublicservants.

Theobjectivesandcriteriausedintheauditarebelow:

Objective:1. TodeterminewhethertheWorkers’CompensationBoardfollowsdefinedpolicies

andprocedurestoprocessclaimsandbenefitsinaccordancewithlegislationandperformanceexpectations.

Criteria:1. TheWorkers’CompensationBoardshouldhavepoliciesandproceduresinplace

toensureclaimsandbenefitsareprocessedinaccordancewiththeWorkers’CompensationAct.

2. TheWorkers’CompensationBoardshouldmakeclaimdecisionsbasedontheestablishedprocessandcommunicatedecisionsinaclearandtimelymanner.

3. TheWorkers’CompensationBoardshouldaccuratelycalculatebenefitsandmakepaymentsincompliancewithclaimdecisions.

4. TheWorkers’CompensationBoardshouldhaveaqualitycontrolprocess.5. TheWorkers’CompensationBoardshouldprovideadequatetrainingandresourcesto

stafftoeffectivelyfulfilltheirroles.

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Objective:1. TodeterminewhethertheWorkers’CompensationBoardfollowsadefinedappeals

processinaccordancewithlegislationandperformanceexpectations.

2. TodeterminewhethertheWorker’sCompensationBoardimplementsappealdecisionsinatimelymanner.

Criteria:1. TheWorkers’CompensationBoardshouldhaveprocessesinplacetosupporttimely

andappropriatedecisionmakingforappeals.2. TheWorkers’CompensationBoardshouldmakeappealdecisionsbasedonthe

processandcommunicatedecisionsinaclearandtimelymanner.3. Whenanewdecisionismadeastheresultofaninternalappeal,theWorkers’

CompensationBoardshouldimplementthedecisioninatimelymanner.4. WhenanewdecisionismadeastheresultofanappealtotheWorkers’Compensation

AppealsTribunal,theWorkers’CompensationBoardshouldimplementthedecisioninatimelymanner.

5. TheWorkers’CompensationBoardshouldprovideadequatetrainingandresourcestostafftoeffectivelyfulfilltheirroles.

Objective:1. TodeterminewhethertheWorkers’CompensationBoardfollowsadefinedprocessto

coordinatereturn-to-workplans.

2. TodeterminewhethertheWorkers’CompensationBoardisevaluatingtheeffectivenessofreturn-to-workplans.

Criteria:1. TheWorkers’CompensationBoardshouldhaveadefinedprocessinplacetodevelop

andcoordinatereturn-to-workplans.2. TheWorkers’CompensationBoardshouldcoordinatereturn-to-workplansbasedon

theprocess.3. TheWorkers’CompensationBoardshouldmonitorandevaluatetheperformanceof

return-to-workplansandconsiderchangestopoliciesbasedonoutcomes.4. TheWorkers’CompensationBoardshouldprovideadequatetrainingandresourcesto

stafftoeffectivelyfulfilltheirroles.

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Objective:1. TodeterminewhetherserviceprovidercontractsareawardedbasedontheWorkers’

CompensationBoard’sprocurementpolicyandmonitoredtoensureservicesarereceived,andpaymentsmade,inaccordancewithcontractterms.

2. TodeterminehowtheWorkers’CompensationBoardassessestheperformanceofserviceprovidercontractsinmeetingthegoalsandobjectivesoftheWorkers’CompensationBoard.

Criteria:1. TheWorkers’CompensationBoardshouldfollowitsprocurementprocesswhen

procuringservices.2. Contractsshouldincludecleartermsandconditions,includingfunding,performance

expectations,andaccountabilityrequirements.3. TheWorkers’CompensationBoardshouldmonitorproviderstoensureservicesare

providedincompliancewithcontracttermspriortoissuingpayment.4. Thereshouldbeprocessestoevaluatecontractperformancetodetermineifthegoals

andobjectivesoftheWorkers’CompensationBoardaremet.5. Timelyactionshouldbetakenwhenperformanceissuesareidentified.

Generallyacceptedcriteriaconsistentwith theobjectivesof theauditdidnotexist. Auditcriteriaweredevelopedspecificallyforthisengagement.CriteriawereacceptedasappropriatebyseniormanagementattheWorkers’CompensationBoard.

Our audit approach consisted of interviews with management and staff of the Workers’CompensationBoard,reviewofpolicy,examinationofprocessesforclaimsmanagement,anddetailedfilereview. Weexaminedrelevantprocesses,plans, reportsandothersupportingdocumentation.OurauditperiodcoveredJanuary1,2016toDecember31,2017.Weexamineddocumentationoutsideofthatperiodasnecessary.

WeobtainedsufficientandappropriateauditevidenceonwhichtobaseourconclusionsonMay10,2019,inHalifax,NovaScotia.

Basedonthereasonableassuranceproceduresperformedandevidenceobtained,wehaveformedthefollowingconclusions:

• TheWorkers'CompensationBoardfollowsthedefinedpoliciesandproceduresinplacetoprocessclaimsandbenefitsinaccordancewithlegislation;however,issuesrelatedtotimelinessandcommunicationofkeybenefitinformationwereidentified.

• TheWorkers’CompensationBoardfollowsadefinedappealprocessinaccordancewithlegislationandperformanceexpectations;however, issueswere identifiedwithprivacybreachesandtimeliness.

• TheWorker’sCompensationBoardhasnoprocesstomonitorthatappealdecisionsareimplemented,andthe implementationprocesswasoftennotstartedwithinthetargettimeframe.

• TheWorkers’ Compensation Board follows a defined process to coordinate return-to-workplans.

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• TheWorkers’CompensationBoardevaluates theeffectivenessof return-to-workplansthroughperformancetargetsandregularreportingtotheBoardofDirectors;however,documentationofactionplansshouldbeimprovedtofacilitatemonitoringandevaluation.

• Service provider contracts are awarded based on theWorkers’ Compensation Board’sprocurementpolicyandmonitoredtoensureservicesarereceived,andpaymentsmade,inaccordancewithcontractterms.

• TheWorkers’CompensationBoardassessestheperformanceofserviceprovidercontractsinmeetingthegoalsandobjectivesoftheWorkers’CompensationBoard.

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AppendixII

BackgroundInformationontheWorkers'CompensationBoard

Workers’ insurancesystemsinCanadaarebasedontheMeredithPrinciples,which includea historic trade-offbetweenworkers and employers. In the event of awork-related injury,workers surrender their right to pursue legal action in exchange for benefits defined inlegislation. Employers are responsible for funding the cost of the system in exchange forimmunitywhenwork-relatedinjuriesoccur. TheWorkers’CompensationActestablishedbygovernmentprovidestheframeworkfortheadministrationofworkplaceinsuranceinNovaScotia,includinginjuriescoveredandbenefitlevels.

TheWorkers’CompensationBoardisresponsibleforadministeringworkers’compensationinlinewiththeActandoperatesatarm’slengthfromgovernment.TheWCBprovidesregularreportingtotheDepartmentofLabourandAdvancedEducationandcollaboratesbyprovidinginputinareasofmutualinterest,suchaslegislativechangesultimatelydecidedbygovernment.

Employersarerequiredtoregisterforcoverageiftheyareconductingbusinessinamandatoryindustryandhavethreeormoreworkersatonetime.CompensationispaidtoinjuredworkersoutoftheAccidentFund,whichisfundedbyannualassessmentscollectedfromemployers.

2017 2016

NumberofCoveredEmployers 19,500 19,100

LabourForceCovered 75% 75%

NumberofClaimsRegistered 23,952 24,311

ClaimsCostsIncurred $219.8million $212.5millionSource: WCB 2017 Annual Report