Workers’ Compensation Chapter 12

Federal vs. State Federal for federal employees, coal miners, long shore and harbor workers Employees under FECA (Federal Employees’ Compensation Act) Provides medical tx, lost wages, voc rehab State for employees of nonfederal employers Each state has own guidelines Covers medical expenses for disability or vocational rehab

Not every business provides Workers’ Comp. What is Workers’ Comp? Type of insurance provided in the workplace for employees who are injured or become ill because of their job. Does not cover if employee is negligent or intoxicated. How is Workers’ Compensation different from a business’s liability insurance? Not every business provides Workers’ Comp. Employee not covered if goofing off, intentionally caused injury, on drugs or intoxicated. Often drug testing right after any accident.

Occupation Safety and Health Administration (OSHA) Federal program that attempts to keep workplace safe for employees. Create and monitor standards When workplace accidents or illnesses happen, OSHA is notified Companies can be fined for having unsafe workplace

Recipients Injury or illness must happen during the course of employment, but could happen off site Must be caused from employment (could be conditions of the workplace or job itself) Considered an accident (not intentional even if caused by another employee) Results in personal injury or illness Injury covered if it takes place away from company site if it is still for work—attending a conference, on a bus attacked or in a car accident uninsured motorist

Not Covered Employees covered by federal program Self-employed Real estate agents (commission workers) Domestic maintenance repair workers Prison inmates employed by prison Clergy and members of religious orders Agriculture laborers Volunteers

Injury or Illness Not Covered When Employee is in violation of health, safety, or legal regulations Employee is intoxicated or on illegal drugs Also receiving SS disability benefits Also receiving unemployment benefits Receiving employer-paid pension or disability

Thinking It Through 12.2 Joe Marino works in the mailroom of a large telecommunications company. His job requires lifting packages in excess of 80 pounds. Over the course of his employment with the company, Joe has been out on temporary disability several times because of back pain. On his way home from work last Friday, Joe stopped by the post office to drop off some personal mail. As he was walking into the post office, he slipped on an icy patch on the sidewalk and injured his back. After an exam by his physician, Joe was ordered to stay out of work for a minimum of 2 weeks. Would this injury be covered under workers’ compensation insurance?

Describe a person who would qualify for a temporary disability claim. Types of Disabilities What is a disability? Inability to perform previous occupational job Inability to perform ANY occupational job Temporary Disability Partial Total Permanent Short-Term disability Long-Term disability Describe a person who would qualify for a temporary disability claim. Partial temporary—cannot do part of your job for a time (can do job, but can’t lift or can’t sit for more than 3 hours at a time) Partial permanent—probably retrain for new career Total Permanent—can no longer work Short term disability—pays while out of work temporarily Longer term—pays when cannot work

Benefits Medical expenses Disability pay Vocational rehabilitation Death benefits Benefits are payable the first day of the injury or illness. Each state has its own way to determine wage –loss benefits Death Benefits for spouse for life or until remarries and dependents under 18 until spouse remarries.

Disability Terms Pain Disability Minimal, slight moderate or sever Limitation to light work Precluding heavy work/very heavy work Precluding heavy/very heavy lifting, repeated bending and stooping Limitation to sedentary work Limitation to semisedentary work

HIPAA and Workers’ Comp Privacy Rule does not apply What is HIPAA’s privacy rule? Keep separate records for Workers’ Compensation Privacy Rule: keeping patient information confidential

Claim Process Report injury to employer right away—first report of injury is filed Carrier determines Admission of Liability Medical service order taken to the doctor (doctor is selected by employer or insurance carrier) Doctor determines % of disability and return-to-work date (Item 16) Doctor files progress reports each visit

Health Professional’s Role Added workload Written and verbal communication with WC, employer, and other providers Additional paperwork—patient files, reports Phone inquiries for completing paperwork and reports Proper documentation

Appealing Decisions PATIENT Contact WC Dept. for new designated doctor WC or doctor (HMO) will have to show criteria for making decisions on ratings—clinical basis Request mediation or hearing DOCTOR Independent Review Organization If WC determines doctor’s services are unnecessary and will not pay, doctor sends request to IRO for review

Managing WC Claims First medical treatment must be exact—it effect future claims When scheduling an appointment, get Date of injury WC carrier information Employer at the time of the injury Patient’s other insurance Contact WC carrier for authorization to treat

Billing Workers’ Compensation Some carriers use CMS1500, HIPAA 837, or own claim form Provider accepts WC allowable Patient cannot be billed or balance billed Signatures are not required Create separate medical files for WC visits Follow guidelines for state the accident took place in

Workers’ Compensation Claim Block 1: other 1a: WC claim number or employee ID# 4: employer’s name 7: insuring (or employer’s) address 10a: YES 10d: used for duplicate or appeal 11c WC insurance claim 12, 13: no signatures required 14 Date of injury or sign of illness 16: use the first full day patient unable to work (documented in first report of treatment)

Completing Claims 18: fill in if hospitalized (inpatient) 23: may be needed for authorization 27: leave blank—all payments go to provider 33a: WC license #

Disability Compensation Government Workers’ Comp Social Security Disability Supplemental Security Income Federal Retirement System Dept. of Veteran Affairs disability Auto Personal Injury Protection