Understanding a Workers Compensation Policy Audit
Most workers' compensation (WC) policies are subject to an audit. Worker's compensation is an insurance program that provides for a replacement of wages when a worker is injured on a job or in the course of their employment. Employers will pay premiums into an approved program that will then be paid to injured workers in the case of a valid claim. The insurance provider will audit the policy held by an employer to make sure it meets the necessary requirements and there are several types of audits they can conduct. Each state will determine the required coverage for the benefits within their boundaries.
Estimated Policy Premium
Your workers' compensation premium is calculated by multiplying a rate times your payroll and dividing the result by 100. For example, suppose that your payroll is $500,000 and the rate is $0.10. Your premium is 500,000 X 0.1 / 100 or $500.
The premium you pay at the beginning of your policy period is a provisional amount. It is an estimate based on your projected payrolls for the coming year. After your policy has expired, your insurer conducts an audit to determine your actual payrolls for that year. Your insurer then adjusts your premium. If your actual payroll exceeds your estimated payroll, you may be billed an additional premium. If your actual payroll is less than your projected payroll, you may receive a return premium.
Purpose of Audit
Audits are performed to ensure that the premiums employers pay for workers' compensation insurance accurately reflect their risks. Insurers check to make sure that employers are properly classified and that the payrolls used for rating purposes are accurate. If an employer's policy contains the wrong classifications or payrolls, the employer may be paying too much or too little, relative to other employers, for workers' compensation insurance.
Many states obligate insurers to audit all workers' compensation policies whose estimated annual premium exceeds a certain threshold, such as $10,000. State insurance departments conduct periodic checks to make sure insurers are performing the required audits.
Most workers' compensation policies, including the standard NCCI form, contain a clause that addresses audits. In the NCCI form, this clause is located under Part Five, Premium. It states that the employer must allow the insurer to audit the policy anytime within three years after the policy has expired. The insurer has the right to examine any records that relate to the policy. These might include accounting ledgers, tax returns, and payroll records.
Workers' compensation policies also contain a provision regarding inspections. In the NCCI form, this provision is located under Part Six, Conditions. It gives the insurer the right to inspect the employer's workplaces at any time. The purpose of such inspections is to assess the insurability of your business and to collect payroll information. Workers' compensation inspections are not intended to be safety inspections.
An insurance policy is a legal contract. When you purchase workers' compensation coverage, you are contractually obligated to comply with the audit and inspection provisions in the policy. If your insurer asks to visit your facility or requests updated payroll information, you must submit to its demands. Failure to do so may constitute a breach of contract. Your insurer may respond to your refusal by canceling your policy or refusing to renew it. This may adversely affect your experience modifier.
Types of Audits
There are several types of workers' compensation audits. The kinds of audits that are available can vary from state to state and insurer to insurer.
The simplest type of audit. Mail audits may be permitted for small employers that don't generate much premium. However, mail audits may be unavailable to employers in certain occupations (such as roofing) regardless of their size.
Conducted when a policy is first written with a new insurer. Preliminary audits are generally performed on-site. Their purpose is to ensure that the proper classifications and payrolls are used on the policy.
Used by some insurers. The insurer may send you a form to complete and return to the insurer. When the insurer has received the information, it schedules a telephone call for you with an auditor to discuss the information you provided.
A physical audit performed at your premises. The purpose is to collect payroll and other information that the insurer will use to calculate your final premium.
May be conducted if your business has changed in some way, perhaps by starting a new operation. Interim audits are also used by large employers who wish to report their payroll monthly or quarterly rather than once a year. These audits are usually conducted by mail. A physical audit is performed at the end of the policy period.
Conducted by a state workers' compensation authority to verify the audit results obtained by the insurer. State bureaus conduct test audits to ensure that insurance auditors are using the classification and rating system properly. The bureaus also want to ensure that insurers are using rating plans approved by the bureau (when prior approval is required).
Fraud by an Employer
Complying with your insurer's request for information is not your only obligation as a policyholder. You must also provide accurate data. If you intentionally supply false information to your insurer, you could be prosecuted by your state's insurance department for insurance fraud. Here are examples of actions that could be considered fraudulent:
- Underreporting your payroll with the intent to reduce your premium
- Providing false job descriptions to an insurance auditor
- Providing phony tax returns or other financial reports
- Concealing the fact that you have hired subcontractors
- Providing falsified certificates of insurance for subcontractors
Once an audit has been completed, your insurer will send you a report. Ideally, the payrolls shown in the report will not differ substantially from the estimated payrolls listed on your policy. Unfortunately, this isn't always the case. If your payroll projections were too low, the audit may have generated a large additional premium. The audit report might also show changes to your classifications. If the auditor determined that your business was misclassified, they may have added new class codes or removed existing ones.
Worker's Compensation Audit Disputes
Policyholders don't always agree with audit reports. A report might contain errors, such as the wrong experience modifier or incorrect payroll figures. Alternatively, it might show classification changes with which you disagree.
If you are unhappy with the results of an audit, contact your insurer immediately. Most insurers provide instructions on how to dispute an audit. These may be included in your policy documents. Be sure to follow the insurer's directions carefully. File your complaint in writing within the time period specified by the insurer. Describe the problem in detail. For instance, if you think the auditor used the wrong classification, explain your reasoning and suggest an alternative. The insurer will review your complaint and decide whether a revision is warranted.
If an audit has generated an additional premium but you have disputed the audit results, your obligation to pay the additional premium should be suspended until the dispute is resolved. If the insurer doesn't address the problem to your satisfaction, you can appeal the insurer's decision to your state workers' compensation board.
The information contained in this article is not tax or legal advice and is not a substitute for such advice. State and federal laws change frequently, and the information in this article may not reflect your own state’s laws or the most recent changes to the law. For current tax or legal advice, please consult with an accountant or an attorney.