Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 15 Workers’ Compensation Insurance Handbook for the Medical Office 13 th edition
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Laws and Benefits 1. State the purposes of workers’ compensation laws. 2. Differentiate between workers’ compensation insurance and employers’ liability insurance. 3. Specify who is eligible for insurance coverage under federal workers’ compensation laws. 4. Name persons entitled to be insured under state workers’ compensation laws. 2 Lesson 15.1
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Laws and Benefits (cont’d) 5. Define second-injury fund. 6. Determine the waiting period in each state before benefits begin. 7. Describe the types of compensation benefits. 8. Define nondisability, temporary disability, and permanent disability claims. 3 Lesson 15.1
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Laws and Benefits (cont’d) 9. List signs of fraud and abuse involving employees, employers, insurers, medical providers, and lawyers. 10. State when to report fraud or abuse involving a workers’ compensation claim. 11. Explain OSHA’s role in protecting employees. 4 Lesson 15.1
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved History First workers’ compensation laws were enacted in Today, all states have workers’ compensation laws. Workers’ compensation is the most important coverage written to insure industrial accidents. 5
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Statutes Federal compensation laws apply to miners, maritime workers, and government workers. State compensation laws apply to employers and employees within each state. 6
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Reform Laws address systematic abuse and fraud Laws vary from state to state Issues include: Proof of medical necessity Preauthorization for treatment Medical bill review Caps on vocational rehabilitation Use of mediators 7
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Purposes of Workers’ Compensation Laws Provide best available medical care to injured Ensure maximum recovery Provide income to injured regardless of fault Reduce overall expenses, resolution time, and litigation Encourage employer workplace safety Promote study of workplace accidents and hazards and facilitate improvements 8
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Self-Insurance Company pays for medical expenses instead of insurance premiums Employee is covered by ERISA Stop-loss provisions may be included Program may involve reinsurance on large claims Captive insurance plans usually serve smaller companies; outside firms may administer claims processing 9
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Eligibility Private business, state, and federal employees are entitled to workers’ compensation coverage A workplace accident that results in injury is covered Illness or disease that results from environmental factors in the workplace is covered 10
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Coverage Federal laws Government employees, such as postal workers and FBI agents Workers in Washington, D.C. Coal miners Maritime workers, such as longshoremen and harbor workers 11
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Coverage State laws Provisions cover workers not covered by federal laws Employer must purchase workers’ compensation insurance from private company or be self-insured with adequate cash reserves Employer must also have employers’ liability insurance 12
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Coverage State laws Provide coverage for minors Most are effective outside the state Provide coverage for civil defense and other volunteer workers Employer and physician requirements for filing injury reports vary by state/territory 13
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved State Laws Second-injury fund (subsequent-injury fund) Covers employee with previous injury or condition who is injured on the job Encourages hiring of the physically handicapped Allocates benefit costs more equitably 14
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved State Laws Minimum number of employees Varies by state/territory Some occupations exempted Waiting periods Required time period must elapse before income benefits are payable 15
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Benefits Medical treatment Temporary disability indemnity Permanent disability indemnity Death benefits for survivors Rehabilitation benefits 16
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Types of State Claims Nondisability (ND): minor injury that requires medical attention but employee is still able to work Temporary disability (TD): unable to perform work duties for a specific time period Permanent disability (PD): unable to return to previous occupation due to residual disability 17
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Fraud and Abuse Physicians are responsible for determining legitimacy of work injuries and accurately reporting findings All individuals who deal with workers’ compensation cases must report suspicious situations to the insurance carrier 18
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Occupational Safety and Health Administration Act of 1970 Act protects employees against workplace health and safety hazards Complaint procedure enables individuals to pursue enforcement measures in their workplace Noncompliance with work standards by employers can result in fines Applies to most businesses 19
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Claims 12. Explain two ways in which depositions are used. 13. Explain the advantages of filing a lien. 14. Define third-party subrogation. 15. Describe workers’ compensation health and financial record-keeping in a medical practice. 16. Explain the procedure of completing the doctor’s first report of occupational injury 20 Lesson 15.2
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Workers’ Compensation Claims (Cont’d) 17. Name the contents of a progress or supplemental medical report. 18. Complete workers’ compensation forms properly. 19. Explain how to handle out-of-state claims. 20. Describe actions to take in following up on delinquent workers’ compensation claims. 21 Lesson 15.2
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Legal Situations Medical evaluator Physician who conducts medical/legal evaluations of injured workers Must first pass a special medical exam for certification by the Industrial Medical Council Hired by insurance company or appointed by appeals board Conducts unbiased assessment of disability 22
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Legal Situations Depositions and medical testimony Discover additional facts from the physician, patient, or other party about a case Proceedings take place under oath but not in open court Findings may be used to impeach (challenge credibility) a witness on cross-examination Findings may be used when case comes to trial Physician should be compensated for time spent preparing to be an expert witness All agreements should be signed by the physician and a lawyer 23
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Legal Situations Liens Legal claim on the property of another for the payment of debt Null and void at the end of a specified time limit Subsequent or amended lien can be filed Should be signed by patient/employee and patient’s attorney 24
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Legal Situations Liens Advantages Court recognizes written agreement Provides protection in event of litigation Ensures payment for medical services Provides inexpensive means to collect full fees Judge determines if fees are reasonable when amount billed is more than amount allowed Helps avoid problems with collections 25
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Legal Situations Third-party subrogation Transfers claims from workers’ compensation insurance carrier to third-party liability carrier Used in events, such as auto accidents, where another party may be liable for the claims Subrogated carrier has legal claim to reimbursement of expenses 26
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medical Reports Health information record keeping Maintain a separate medical record Maintain a separate financial ledger Keep appointments for occupational injury or illness separate from unrelated matters Keep documentation or dictation for each appointment separate 27
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medical Reports Terminology Most workers’ compensation cases involve accidents causing bodily injury Become familiar with anatomic terms, directional and ROM words, types of fractures, body activity terms, and words that describe pain and symptoms 28
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Reporting Requirements Employer’s report Employer must file report within a specified time limit Medical service order Authorizes a physician to treat the injured employee 29
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Reporting Requirements Physician’s First Report Physician must complete standard form or narrative letter after first exam of the employee Original to insurance carrier Copies to: State agency Patient’s employer Physician’s file 30
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Reporting Requirements Progress or supplemental report Supplemental report Sent to the insurance carrier after 2 to 4 weeks of treatment to note current status Progress report Sent to the insurance carrier if there is significant change in prognosis or status 31
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Submission Financial responsibility Workers’ compensation insurance is billed for all expenses Physician agrees to accept payment according to carrier’s fee schedule Patient’s health insurance information should also be obtained and filed in case of non-related medical expenses 32
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Submission Fee schedules May follow special workers’ compensation or Medicare fee schedule Some include maximum reimbursement amounts Employer, state agency, insurance carrier, or payer may audit or review fees 33
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Submission Electronic claims submission and reports Carriers may have separate claim for workers’ comp (not CMS-1500 [02-12]) Electronic system or telephone submission 34
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Reporting Requirements Out-of-state claims Follow regulations for state in which injured worker was hired Obtain and follow out-of-state fee schedule for billing purposes 35
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Reporting Requirements Delinquent or slow pay claims Phone patient’s employer to verify information Send copy of claim form and itemized account statement to carrier Phone insurance carrier after 45 days and request expected date of payment Send employer copy of financial account statement with outstanding balance Contact state board if employer fails to file Employer’s Report of Work Injury 36
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 37