1. Workers Compensation Basics Prepared for Fresno County Self Insurance Group-FCSIG

2. Tristar Contact Information  Karen Valdez, Claims Supervisor Ph: 559-432-1260 ext.3316 Fax: 559-432-1267 E-mail: karen.valdez@tristargroup.net@tristargroup.net Lucy Vue, Claims Examiner Phone: 559-432-1260 ext. 3325 Fax: 559-432-1267 Email: lucy.vue@tristargroup.netlucy.vue@tristargroup.net  Lisa Ross, Senior Claims Examiner (B0-Gr) Ph: 559-432-1260 ext. 3327 E-mail: lisa.ross@tristargroup.net@tristargroup.net  Debra Pettigrew, Senior Claims Examiner (Gu-O) Ph: 559-432-1260 ext. 3322 E-mail: dale.olson@tristargroup.net@tristargroup.net  Bruce Vue, Claims Examiner (P-Z) Ph: 559-432-1260 ext. 3333 E-mail: bruce.vue@tristargroup.net@tristargroup.net

3. The Claims Process:  Pre-Injury  Post-Injury

4. Pre-Injury  Posting Notice Employer must designate and post who they wish to designate as their treating physician/occupational clinic.  Facts About Workers’ Compensation Pamphlet  Notify Employee of right to pre-designate a physician  MPN Enrollment Document All 3 items given to the employee at time of hire.

5. Post-Injury  When an Injury Occurs An employee should immediately report any injury to the employer when it occurs. For Serious Injuries, dial 911 for immediate medical assistance. For all other injuries, direct the employee to immediately seek treatment from the designated provider. Employer should initiate accident investigation For serious injuries & fatalities, contact Tristar and OSHA within 24 hours.

6. Reporting the Claim  Employer must complete the Employer’s First Report of Injury Form (5020).  Employer must personally provide the employee with an Employee’s Claim for Workers’ Compensation (DWC1) within 24 hours. If it can’t be personally delivered, send via registered mail.

7. Reporting the Claim  If you dispute the injury, please notify Tristar on the initial paperwork or during the first contact call. The employer must pay for up to $10,000 of medical treatment during the period of delay.  Additionally, Tristar should be made aware of any other notable issues or concerns regarding the injury.

8. Types of Workers Comp Claims  First Aid / Record Only  Medical Only  Indemnity / Lost Time

9. Medical Only Claims  Injury results in medical treatment, but no lost time from work and no indemnity benefits being paid.  Most of these close within 90 days of being opened.

10. Indemnity/Lost Time Claims  Injury results in lost time from work and/or permanent impairment, in addition to medical treatment, for which indemnity benefits are paid.  These are the complex claims that account for the majority of workers compensation costs.

11. Roles & Responsibilities of the Parties

12. Parties to the Claim Process  Employee  Employer  Tristar Claims Team  Medical Provider  Nurse Case Manager  Utilization Review

13. Employee  Report injury immediately  Participate in medical treatment with authorized provider  Understand and adhere to modified work restrictions  Notify Human Resources if asked to work outside their restrictions

14. Employer  Develop modified job opportunities  Create sample job descriptions  Establish procedures and expectations  Communicate procedures and expectations to all participants  Maintain contact with employees prior to return to work  Monitor employees to ensure restrictions are not exceeded  Choose medical provider with care

15. Tristar Claims Team  Communicate with all parties  Investigation  Compensability Determination  Subrogation  Reserve Analysis  Return to Work  Medical Management  Compliance with State Regulations  Litigation Management  Settlements  Claim Resolution, Completion and Closure

16. Medical Provider  Timely Communication of Employee’s status and progress  Provide appropriate treatment to the employee  Maintain and Monitor treatment plan and recovery  Understand and support RTW program  Identify functional abilities, not just restrictions  Understand the regular job duties, as well as modified job duties

17. Nurse Case Manager  Provide a resource to the injured worker to assist with obtaining needed medical treatment, and answer questions of a medical nature.  Assist Employer and Claims Examiner in keeping claim on track and moving toward resolution  Obtain medical updates from the provider  Obtain work preclusions from the medical provider to facilitate early return to work  Coordinate medical appointments and equipment as needed  Attend appointments when needed

18. Utilization Review  Ensures treatment provided is appropriate to the injury by referencing established medical treatment guidelines.  UR determinations are presumptively correct under the law  Peer-to-Peer Physician Review for treatment not addressed in treatment guidelines

19. Other Services  Medical Provider Network  Medical Bill Review  Strategic Partners / Provider Networks

20. How You can make a Difference  Be a Safety Role Model: Practice, Observe, Teach and Speak “Safety”  File your claims within 24 hours  Direct medical treatment at the onset of the claim  Ongoing communication with your employee and Tristar Claims Examiner reduces costs and litigation

21. How You can make a Difference  Develop and maintain an aggressive early return to work program.  Be a Fraud Fighter! Report suspicious activity to Tristar immediately.  Take precautions and be aware of how you communicate with others to protect your organization from discrimination lawsuits.  Take action on performance problems, before they become workers’ compensation problems.

22. Return to Work  Employees can be brought back to work on modified duty to reduce Temporary Disability Benefits  It is the employee’s obligation to report work restrictions to employer  Tristar monitors disability status and reports when employee is released to modified duty.

23. Return to Work Continued  Job Description – helps Doctor determine if employee can return to work  Permanent Work Restrictions  Employee is eligible for supplement job displacement voucher if unable to return to work at employer

24. Questions & Answers