1 Workers Compensation and Disability Chapter 13 © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

Chapter 132 Learning Outcomes After studying this chapter, you should be able to: 13.1List the four federal workers' compensation plans. 13.2Describe the two types of workers' compensation benefits that are offered by states. 13.3List the criteria an injury must meet to be considered a covered injury or illness. 13.4List the five classifications of work-related injuries.

Chapter 133 Learning Outcomes (Continued) 13.5List three responsibilities of the physician of record in a workers' compensation case. 13.6Explain the difference between workers' compensation insurance and disability compensation programs. 13.7Explain the difference between Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).

Chapter 134 Key Terms Admission of Liability Disability compensation programs Federal Employees Compensation Act (FECA) Federal Insurance Contribution Act (FICA) Final report First report of injury Independent medical examination (IME) Notice of Contest Occupational diseases or illnesses

Chapter 135 Key Terms (Continued) Occupational Safety and Health Administration (OSHA) Office of Workers' Compensation Programs (OWCP) Physician of record Progress report Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Vocational rehabilitation

Chapter 136 Workers Compensation Workers compensation was developed to benefit both the employer and the employee. Employees receive compensation for injuries received while on the job. Employers are protected against liability for employees injuries.

Chapter 137 Occupational Safety and Health Administration OSHA protects workers from health and safety risks on the job Employees may file complaints directly with OSHA

Chapter 138 Federal Workers Compensation Plans Federal Employees Compensation Program Federal Black Lung Program Energy Employees Occupational Illness Compensation Program Longshore and Harbor Workers Compensation Program Civilian employees of federal agencies are covered under these programs

Chapter 139 Federal Workers Compensation Plans Federal Employees Compensation Program Federal Black Lung Program Energy Employees Occupational Illness Compensation Program Longshore and Harbor Workers Compensation Program Provides FECA benefits

Chapter 1310 Federal Workers Compensation Plans Federal Employees Compensation Program Federal Black Lung Program Energy Employees Occupational Illness Compensation Program Longshore and Harbor Workers Compensation Program For individuals working in coal mines

Chapter 1311 Federal Workers Compensation Plans Federal Employees Compensation Program Federal Black Lung Program Energy Employees Occupational Illness Compensation Program Longshore and Harbor Workers Compensation Program For workers who have developed cancer and other diseases while working at atomic weapons facilities

Chapter 1312 Federal Workers Compensation Plans Federal Employees Compensation Program Federal Black Lung Program Energy Employees Occupational Illness Compensation Program Longshore and Harbor Workers Compensation Program For workers in the maritime field These plans are administered by the Office of Workers Compensation Programs (OWCP) of the US Department of Labor

Chapter 1313 State Workers Compensation Plans Each state –administers its own workers compensation program –has coverage that may vary from other states

Chapter 1314 State Workers Compensation Plans Employers may purchase or obtain workers compensation insurance from –State workers compensation fund –Private insurance company –Directly, through a self-insured fund

Chapter 1315 State Workers Compensation Plans Two types of workers compensation benefits include: Medical Expenses –Pays medical expenses for work related injuries or illnesses Lost Wages –Pays for lost wages while the worker is unable to return to work

Chapter 1316 Covered Injuries and Illnesses Covered injuries or illnesses must: Result in injury or death Occur by accident Arise out of employment Occur during the course of employment

Chapter 1317 Exclusions to Covered Injuries and Illnesses Employee intoxication led to the injury Injury was intentionally self-inflicted Employee violated the law Employee failed to use safety equipment Employee failed to obey safety procedures

Chapter 1318 Exclusions to Covered Injuries and Illnesses Employee also receives Social Security disability benefits Employee receives unemployment insurance Employee receives an employer-paid pension or disability benefit

Chapter 1319 Classifications of Injuries Injury without disability Injury with temporary disability Injury with permanent disability Injury requiring vocational rehabilitation Injury resulting in death

Chapter 1320 Workers Compensation Terminology Terminology is agreed upon by state compensation commissions and carriers Leads to a common understanding of patients condition Defines: –Pain levels –Disability levels for heart disease, pulmonary dysfunction, abdominal weakness, or spinal injuries –Disability levels due to lower extremity injuries

Chapter 1321 Workers Compensation and the HIPAA Privacy Rule One of few times a provider may disclose patients PHI to an employer without patients authorization Most states also allow claims adjusters and employers unrestricted access to workers compensation files

Chapter 1322 Claim Process Physician Responsibility The physician who first treats the injured or ill employee is known as the physician of record

Chapter 1323 Physician Responsibility The physician of record is responsible for Treating the injured or ill worker Filing progress reports Determining the percentage of disability Determining the return to work date

Chapter 1324 First Report First Report of Injury or Illness: Prepared by provider –Dates and treatments –Patients history and description of injury/illness –Name and address of employer and supervisor –Detailed description of physical findings, results of x-rays, diagnostic tests –Diagnosis and clinical treatment –Physicians opinion of relationship between the work environment and the injury/illness and how physician arrived at that opinion Submitted ASAP No patient signature required

Chapter 1325 Progress Reports Progress or Supplemental Reports –Submitted by provider –Report changes in employees health status –Work status, ability to perform tasks, anticipated additional treatment, and extent of loss/disability Final report –Submitted by provider when treatment is completed

Chapter 1326 Employer and Insurance Carrier Responsibility Employer or physician must file first report of injury within a certain time period (defined by state) Insurance carrier –Assigns a claim number to the case –Determines whether claim is eligible –Notifies employer

Chapter 1327 Billing and Claim Management Workers compensation covers providers charges –Other coverage may begin when workers compensation benefits are exhausted Each state has its own forms and regulations Narrative reports may be required HIPAA 837 or CMS-1500 is usually used

Chapter 1328 Billing and Claim Management Establish a separate record for workers compensation cases –Cases are subject to review and court hearings –Law allows review of only history and treatment records that pertain to work-related injury/illness –No patient authorization is required to disclose the information to the appropriate party State-assigned case number should be used on all claims and reports

Chapter 1329 Disability Compensation Programs Disability compensation programs provide payment for lost income due to injury or illness (mostly non-work related) – not medical expenses Federal, state, and private carriers –Eligibility and benefits vary –Convincing medical evidence that the condition resulting from injury/illness satisfies the criteria in the program/policy

Chapter 1330 Social Security Disability Insurance (SSDI) A government disability program defined through Social Security Act Funded by workers payroll deductions and matching employer contributions Employee deductions are known as Federal Insurance Contribution Act (FICA) deductions

Chapter 1331 Supplemental Security Income ( SSI) A welfare program Provides payments to individuals in need –including aged, blind, and disabled individuals Eligibility is determined using nationwide standards

Chapter 1332 Federal Employees Retirement System (FERS) Covers federal workers hired after 1984 Prior to 1984, covered by Civil Service Retirement System (CSRS) Consists of federal disability program AND Social Security disability program –Each part has different eligibility rules –Person may qualify for one or both programs –If eligible for both, SSDI payment is reduced by amount of FERS payment

Chapter 1333 Veterans Compensation Program and Veterans Pension Program Certain veterans may qualify for both federal programs VCP provides coverage for individuals with permanent and total disability resulting from a service-related injury/illness –Disability must affect earning capacity VCP provides benefits for service-related permanent disability to those who are unable to obtain gainful employment

Chapter 1334 Preparing Disability Reports Medical insurance specialists do not file claims; do provide physicians medical report and medical records Includes: –Medical history –Clinical signs and symptoms –Diagnosis –Treatment plan –Prognosis –Patients ability to perform work-related functions –Results of test, with copies of reports Possible CPT codes: E/M or or 99456