Copyright © 2008 Delmar Learning. All rights reserved. Chapter 17 Workers’ Compensation

Copyright © 2008 Delmar Learning. All rights reserved. 2 Introduction Federal and state laws require employers to maintain workers’ compensation coverage to meet minimum standards, covering a majority of employees for work- related illnesses and injuries.

Copyright © 2008 Delmar Learning. All rights reserved. 3 Federal Workers’ Compensation Programs U.S. Department of Labor’s Office of Workers’ Compensation Programs administer programs that make available: –Wage replacement benefits –Medical treatment rehabilitation training –Other benefits

Copyright © 2008 Delmar Learning. All rights reserved. 4 Federal Workers’ Compensation Programs Energy Employees Occupational Illness Compensation Program Federal Black Lung program Federal Employees’ Compensation Act Program Longshore and Harbor Workers’ Compensation Program

Copyright © 2008 Delmar Learning. All rights reserved. 5 Federal Workers’ Compensation Programs Department of Labor also designed these programs to prevent work-related injuries and illnesses: –Mine Safety and Health Administration –Occupational Safety and Health Administration

Copyright © 2008 Delmar Learning. All rights reserved. 6 Other Federal Programs Federal Employment Liability Act Merchant Marine Act

Copyright © 2008 Delmar Learning. All rights reserved. 7 Energy Employees Occupational Illness Compensation Program Provides benefits to employees that qualify under the Department of Energy

Copyright © 2008 Delmar Learning. All rights reserved. 8 Federal Black Lung Program Provides medical treatment and other benefits for respiratory conditions related to former employment in the nation’s coal mines.

Copyright © 2008 Delmar Learning. All rights reserved. 9 Federal Employees’ Compensation Act Program Federal Employees’ Compensation provides coverage to all federal and postal workers throughout the world for employment-related injuries and occupational diseases.

Copyright © 2008 Delmar Learning. All rights reserved. 10 Longshore and Harbor Workers’ Compensation Program Provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers.

Copyright © 2008 Delmar Learning. All rights reserved. 11 Mine Safety and Health Administration Helps to reduce deaths, injuries, and illnesses in U.S. mines through a variety of activities and programs

Copyright © 2008 Delmar Learning. All rights reserved. 12 Occupational Safety and Health Administration Protect employees against injuries from occupational hazards in the workplace

Copyright © 2008 Delmar Learning. All rights reserved. 13 Federal Employment Liability Act Provides railroad employees with protection from employer negligence

Copyright © 2008 Delmar Learning. All rights reserved. 14 Merchant Marine Act Not a workers’ compensation statute –Provides seamen with the same protection from employer negligence

Copyright © 2008 Delmar Learning. All rights reserved. 15 State Workers’ Compensation Program Weekly cash payments and reimburses health care costs –For covered employees who develop a work-related illness or sustain an injury on the job

Copyright © 2008 Delmar Learning. All rights reserved. 16 State Workers’ Compensation Program State Insurance fund –Provides workers’ compensation insurance coverage to private and public employers Self-insurance plans –Employers with sufficient capital to qualify can self-insure

Copyright © 2008 Delmar Learning. All rights reserved. 17 State Workers’ Compensation Program Commercial workers’ compensation insurance: –Employers are permitted to purchase policies from commercial insurance companies

Copyright © 2008 Delmar Learning. All rights reserved. 18 State Workers’ Compensation Program Combination programs –Employers in some states are allowed to choose a combination of any of the above to comply with workers’ compensation coverage

Copyright © 2008 Delmar Learning. All rights reserved. 19 Classification of Workers’ Compensation Cases Federal law mandates the following classifications: –Medical treatment –Temporary disability –Permanent disability –Vocational rehabilitation –Survivor benefits

Copyright © 2008 Delmar Learning. All rights reserved. 20 Medical Treatment Easier to process –Employee continues to work or returns to work within a few days

Copyright © 2008 Delmar Learning. All rights reserved. 21 Temporary Disability Covers health care treatment for illness and injuries

Copyright © 2008 Delmar Learning. All rights reserved. 22 Permanent Disability Diminished capacity to return to work Subclassifications: –Permanent total disability –Permanent partial disability –Schedule loss of use –Disfigurement

Copyright © 2008 Delmar Learning. All rights reserved. 23 Vocational Rehabilitation Claims cover expenses for vocational retraining for both temporary and permanent disability cases

Copyright © 2008 Delmar Learning. All rights reserved. 24 Survivor Benefits Claims provide death benefits to eligible dependents

Copyright © 2008 Delmar Learning. All rights reserved. 25 Workers’ Compensation and Managed Care Both employees and employers have gained from incorporating managed care into workers’ compensation programs –In so doing improving the quality of medical benefits and services provided

Copyright © 2008 Delmar Learning. All rights reserved. 26 Benefits Include More comprehensive coverage –Because states continue to eliminate exemptions under current law

Copyright © 2008 Delmar Learning. All rights reserved. 27 Benefits Include Expanded health care coverage –If injury or illness is work-related and the treatment/service is reasonable and necessary Provision of appropriate medical treatment –To facilitate healing and promote prompt return to work

Copyright © 2008 Delmar Learning. All rights reserved. 28 Benefits Include Internal grievance and dispute resolution procedures involving the care and treatment provided by the workers’ compensation program –Along with an appeals process to the state workers’ compensation agency

Copyright © 2008 Delmar Learning. All rights reserved. 29 Benefits Include Coordination of medical treatment and services with other services designed to get workers back to work.

Copyright © 2008 Delmar Learning. All rights reserved. 30 Benefits Include No out-of-pocket costs for coverage or provision of medical services and treatment –Cost/time limits do not apply when an injury or illness occurs

Copyright © 2008 Delmar Learning. All rights reserved. 31 First Report of Injury Patient comes in for work-related injury –Report of injury forms should be completed –Copy should be given to each of the following: State Workers’ Compensation Board/Commission Employer-designated compensation payer Ill or injured party’s employer Patient’s work-related injury chart

Copyright © 2008 Delmar Learning. All rights reserved. 32 Necessary Information Name and address of present employer Name of immediate supervisor Date and time of accident or onset of disease Site where injury occurred Patient’s description of onset of disorder

Copyright © 2008 Delmar Learning. All rights reserved. 33 Progress Reports Should be filed to show any changes in a worker’s medical or disability status

Copyright © 2008 Delmar Learning. All rights reserved. 34 What Should be Documented Patient’s name and compensation file/case number Treatment and progress report Work status at the present time Statement of further treatment needed

Copyright © 2008 Delmar Learning. All rights reserved. 35 What Should be Documented Estimate of the future status with regard to work or permanent loss or disability Copies of substantiating x-ray, laboratory, or consultation reports Physician should sign original and photocopies of reports

Copyright © 2008 Delmar Learning. All rights reserved. 36 Fraud and Abuse Occurs when individuals knowingly obtain benefits for which they are not eligible

Copyright © 2008 Delmar Learning. All rights reserved. 37 Fraud and Abuse Employer fraud –Employer misrepresents payroll amounts Employee fraud –Lies or provides false statements Provider fraud –Inflate bills for services for nonwork-related illnesses

Copyright © 2008 Delmar Learning. All rights reserved. 38 Special Handing Contact employer immediately when an injured worker presents for first visit without a written or personal referral from the employer.

Copyright © 2008 Delmar Learning. All rights reserved. 39 Private Payer Mistakenly Billed When a patient fails to notify a provider that a sickness or injury is work-related –Patient’s primary payer is billed for services or procedures rendered