©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry ® 1 California Medical Bill Reviewer Re-Certification Unit 1: Workers Compensation Benefit Program Module 1: The Injured Worker

2 CA Regulations Training – Injured Worker March 2010 Overview Hi! In this module, you will learn about California workers compensation, a workers rights to benefits, who is involved in the process, and their responsibilities. History of Workers Compensation in California Workers Rights to Benefits Workers Compensation: Whos Involved? Lets start by discussing the history of workers compensation... History of Workers Compensation in California

3 CA Regulations Training – Injured Worker March 2010 Workers Compensation is Born Workers compensation programs were developed in the early 20 th century to provide protection to both injured workers and their employers. The State of California was one of the first states to adopt a workers compensation system.

4 CA Regulations Training – Injured Worker March 2010 Compensation Act of : The first workers compensation law in California was established under the Compensation Act of Employer participation in the workers compensation program was voluntary.

5 CA Regulations Training – Injured Worker March 2010 Growth and Change: The Boynton Act 1913: A mandatory system was established in California as the Workers Compensation, Insurance, and Safety Act of Required that all employers provide compensation benefits to all of their employees. Protected employers from being sued by their employees for their injuries. Prevented employees from receiving monetary compensation for pain and suffering or punitive damages.

6 CA Regulations Training – Injured Worker March 2010 Workers Compensation Benefits These initial steps are the foundation of todays workers compensation program in California. These benefits include: medical care for injury or illness temporary disability benefits permanent disability benefits vocational rehabilitation services supplemental job displacement benefits death benefits Under California Labor Code Section 3700, all employers in the State of California are required to provide workers compensation benefits to their employees.

7 CA Regulations Training – Injured Worker March 2010 A Workers Rights Every worker in California is entitled to workers compensation benefits for injuries or illnesses that occur while they are working. Workers compensation is a no-fault system. This means that the injured worker does not have to prove that his injury was by the fault of someone else.

8 CA Regulations Training – Injured Worker March 2010 California Workers Compensation Injured Workers Labor Unions Insurance Companies Employers Attorneys Service Providers Regulation Agencies Californias workers compensation program is a large melting pot of many different entities.

9 CA Regulations Training – Injured Worker March 2010 How Do Employers Provide WC Benefits? Workers compensation benefits are a type of insurance. Option 2 Option 1 Most employers obtain workers compensation policies from insurance carriers authorized to provide workers compensation. Some employers are self-insured, and provide their own workers compensation benefits to their employees.

10 CA Regulations Training – Injured Worker March 2010 Roles & Responsibilities Now that you understand the basics of workers comp, lets take a look at the responsibilities of all of the parties involved. Roles and Responsibilities: Injured Workers Employers Providers Insurance Carriers Roles and Responsibilities: Injured Workers Employers Providers Insurance Carriers

11 CA Regulations Training – Injured Worker March 2010 The Injured Worker When an employee becomes sick or injured at work, he or she typically notifies his or her supervisor of the injury. The employer provides the worker with a claim form, which is used to officially report the injury or illness.

12 CA Regulations Training – Injured Worker March 2010 The Employers Role The employer must authorize medical treatment for the injured worker within one day of submitting the claim to the insurance company. The employer submits the claim to the insurance carrier that holds the companys workers compensation policy.

13 CA Regulations Training – Injured Worker March 2010 The Providers Role For the first 30 days post injury, the employer usually dictates the medical treatment that the injured worker receives. Providers submit a bill to the insurance carrier for the services rendered, and are reimbursed according to the rates specified in the California Fee Schedule. The injured worker seeks medical treatment from an appropriate provider.

14 CA Regulations Training – Injured Worker March 2010 The Insurance Carriers Role Claims administrators initiate and process claims that are submitted to an insurance company. Claims administrators may interview the employer and the injured worker to determine if the claim should be accepted, denied, or delayed. Claims administrators oversee a claim and make sure that the injured worker receives the appropriate medical care and disability benefits.

15 CA Regulations Training – Injured Worker March 2010 Workers Compensation Claims Most workers compensation claims are small claims. Medical Benefits Back at Work Small Claim Characteristics: Small claims typically only require that the injured worker receives medical benefits. The injured worker receives medical treatment and usually returns to work within a few days of his injury. Small claims account for more than 75% of all workers compensation claims.

16 CA Regulations Training – Injured Worker March 2010 Workers Compensation Claims More complex claims make up the remainder of workers compensation claims. Medical Benefits Disability Benefits Vocational Rehab Complex Claim Characteristics: Complex claims usually require that the injured worker receives more than medical benefits. The injured worker may receive temporary or permanent disability benefits, or vocational rehabilitation services. Complex claims may require litigation.

17 CA Regulations Training – Injured Worker March 2010 So What Is Your Job? Your job as a medical bill reviewer is to process bills for services rendered so that all individuals who are due payment are reimbursed correctly for their services. Payment recommendations are sent to the insurance carrier and/or the provider.

18 CA Regulations Training – Injured Worker March 2010 Summary How workers compensation was developed. The types of workers compensation benefits. An individuals right to workers compensation benefits. The many roles of individuals involved in workers compensation.