1. Workers’ Compensation
Chapter 12

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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?

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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 #

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