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

Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 17

Workers’ Compensation


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.


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


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• Energy Employees Occupational Illness Compensation Program

• Federal Black Lung program

• Federal Employees’ Compensation Act Program

• Longshore and Harbor Workers’ Compensation Program


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• Department of Labor also designed these programs to prevent work-related injuries and illnesses:– Mine Safety and Health Administration – Occupational Safety and Health

Administration


6

Other Federal Programs

• Federal Employment Liability Act

• Merchant Marine Act


7

Energy Employees OccupationalIllness Compensation Program

• Provides benefits to employees that qualify under the Department of Energy


8

Federal Black Lung Program

• Provides medical treatment and other benefits for respiratory conditions related to former employment in the nation’s coal mines.


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.


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.


11

Mine Safety and Health Administration

• Helps to reduce deaths, injuries, and illnesses in U.S. mines through a variety of activities and programs


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Occupational Safety and Health Administration

• Protect employees against injuries from occupational hazards in the workplace


13

Federal Employment Liability Act

• Provides railroad employees with protection from employer negligence


14

Merchant Marine Act

• Not a workers’ compensation statute– Provides seamen with the same protection

from employer negligence


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


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• 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


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• Commercial workers’ compensation insurance: – Employers are permitted to purchase

policies from commercial insurance companies


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• Combination programs– Employers in some states are allowed to

choose a combination of any of the above to comply with workers’ compensation coverage


19

Classification of Workers’ Compensation Cases

• Federal law mandates the following classifications:– Medical treatment – Temporary disability – Permanent disability – Vocational rehabilitation – Survivor benefits


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Medical Treatment

• Easier to process– Employee continues to work or returns to

work within a few days


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Temporary Disability

• Covers health care treatment for illness and injuries


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Permanent Disability

• Diminished capacity to return to work

• Subclassifications: – Permanent total disability– Permanent partial disability– Schedule loss of use– Disfigurement


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Vocational Rehabilitation

• Claims cover expenses for vocational retraining for both temporary and permanent disability cases


24

Survivor Benefits

• Claims provide death benefits to eligible dependents


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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


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Benefits Include

• More comprehensive coverage– Because states continue to eliminate

exemptions under current law


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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


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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


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Benefits Include

• Coordination of medical treatment and services with other services designed to get workers back to work.


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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


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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


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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


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Progress Reports

• Should be filed to show any changes in a worker’s medical or disability status


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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


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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


36

Fraud and Abuse

• Occurs when individuals knowingly obtain benefits for which they are not eligible


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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


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Special Handing

• Contact employer immediately when an injured worker presents for first visit without a written or personal referral from the employer.


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

Documents

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