Ch 12: Workers; Compensation and Disability/Automotive Insurance

Developed benefit both the employerFederal agency that regulates workers’ health and safety risks in the workplace. and employee

**Occupational Safety and Health Administration (OSHA)**

*1970*

Federal agency that regulates workers’ health and safety risks in the workplace.

**Office of Workers’ Compensation Programs (OWCP)**

*part of US Department of Labor*

The office of the U.S. Department of Labor that administers the Federal Employees’ Compensation Act which covers work-related injuries of illnesses suffered by civilian employees of federal agencies.

Programs of US Department of Labor:

* Federal Employees’ Compensation Program (FECA)
* Federal Black Lung Program
* Energy Employees Occupational Illness Compensation Program
* Longshore & Harbor Workers; Compensation Program

Each program provides medical treatment, cash benefits for lost wages, vocation rehabilitation, + other benefits to workers of the employee group or industry it represents who have sustained workplace injuries or acquired occupational diseases.

> physician from OWCP that’s treating, directly paid based on Medicare Fee Schedule

State workers’ compensation plans

Obtained from:


1. A state workers’ compensation fund
2. Private plan
3. Directly with a self-insured fund

Must file proof of workers’ compensation insurance with the state Workers’ Compensation Board’ maybe through Web-based data-entry application + employer must post a Notice of Workers’ Compensation Coverage in place accessible to all employees.

State workers’ compensation programs are administered and governed by __each state.__

All states provide coverage for medical expenses and wage compensation.

Workers' compensation plans vary from state to state.

Each state administers its own program.

* Companies pay premiums to a central state insurance fund (how workers’ compensation insurance is funded under a state fund)

State Workers’ Eligibility

Most states require that public & private CO to provide workers’ compensation coverage to all full-time & part-time employees + minors in organization with 3+ ppl.

Not covered:

* Federal employees (under a fed program)
* Railroad employees (under fed program)
* Self-employed individuals
* Real estate agents working on commission
* For-hire domestic, maintenance, or repair workers hired to perform a job for a homeowner on less than a full-time basis
* Drivers under a lease agreement with carrier, eg. long-haul truck drivers
* Inmates employed by a prison
* Volunteers
* Independent contractors
* Clergy & members of religious orders
* Agricultural

When a worker is injured on the job, requires treatment, and is unable to return to work within several days, the worker is eligible for having all medical expenses paid and compensation for lost wages.

Benefits

Cash benefits vary from state and generally not paid first 7days of disability, most states 7+ months before benefits are payable.

**occupational disease or illness**

*non-traumatic injuries*

Condition caused by the work environment over a period longer than one workday or shift; develop → workplace conditions or activities.

eg. lung disorders → poor quality of air, repetitive motion illnesses such as carpal tunnel syndrome, occupational hearing loss.

Covered Injuries and illnesses

States determine types of injuries covered under workers’ compensation:

* Result of personal injury/death
* Occurs by accident
* Arises from employment
* Occurs during course of employment

Covered injuries:

* Back injuries → heavy lifting/falls
* Repetitive stress eg. carpal tunnel syndrome
* Parking lot injuries eg. falls
* Heat-related injuries eg. heat stroke/heat exhaustion if job requires a lot of work time in the hot sun
* Hernias if related to a work injury
* Personal time injuries, eg. injuries occurring in cafeteria/restroom

Excluded:

* Employee intoxication by alcohol or illegal drugs led to the injury
* Injury intentionally made by self
* Employee violated law
* The employee failed using safety equipment
* Failed to obey safety procedures
* Recipient of Social Security disability benefits
* Employee is also a recipient of unemployed insurance
* Receives an employer-paid pension or disability benefit

FECA

Individuals employed by the federal government are provided workers' compensation.

Classification of injuries

^^*Injury without disability*^^*:* workers’ compensation insurance pays all medical expenses for a worker who is injured on the job + requires treatment but **is** able to resume working within several days.

%%*Injury with Temporary Disability*%%*:* worker injured on job, requires treatment, **unable** to return to work within several days; all medical expenses paid by workers’ compensation insurance + employee receives compensation for lost wages. Compensation varies from state, usually % of workers’ salary before injury. Physician must file final report stating the worker is fit to return to work and resume normal job activities.

Injury with Permanent Disability: worker injured on job, requires treatment, unable to return to work, not expected to be able to return to job. employee on temporary disability for extended period of time and unable to resume. Physician of record files report for being permanently disabled. State workers’ compensation office/insurance carrier may request additional medical opinion before final determination is made. Impartial physician called to provide IME → final determination of disability is made → settlement reached. Length of coverage varies in state. Workers’ compensation pays all medical expenses + worker receives compensation for lost wages (depending on whether disability is partial/total, employee age, job performed before injury. Partial disability -- generally classified by percentage and varies by severity.

@@*Injury Requiring Vocational Rehabilitation:*@@ worker injured on job, requires treatment, unable to return to work without vocational rehabilitation. Workers’ compensation insurance pays al medical expenses + costs of vocational rehab program.

^^*Injury Resulting in Death*^^*:* worker dies due to injury on job. Death benefits paid to survivors based on the worker’s earning capacity at the time of the injury.

**independent medical examination (IME)**

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Examination by a physician conducted at the request of a state workers’ compensation office or an insurance carrier to confirm that an individual is permanently disabled.

Vocational rehabilitation

Retraining program covered by workers’ compensation to prepare a patient for reentry into the workforce.

Pain disability

Pain terminology: pain is classified as __minimal, slight, moderate, or severe__ --

* Minimal pain: annoying, not interfere with ability to perform job
* Slight pain: tolerable, performance may be impaired on some work assignments
* Moderate pain: tolerable, but performance of some work assignments will show marked impairment
* Severe pain: requires avoiding activities that lead to pain

Disability terminology

Limitation to light work: employee may work in an upright or walking position when no more than minimal effort is required

Precluding heavy work: employee last 50%

HIPAA Privacy Rule for workers’ compensation purposes

Disclosure for any judicial proceedings without patient's authorization

Covered entities are permitted to reasonably assume that the information requested is the minimum necessary for the intended purpose.

Unrestricted access to the workers' compensation files; cases are among the few situations in which a healthcare provider may disclose a patient's PHI to an employer without the patient's authorization.

Claim process

When injured on job, must be reported to employer within certain period. Most states require notification in writing. Once notified → employer must notify state workers’ compensation office and insurance carrier, within certain period of time. Injured employee treated by provider selected by employer or insurance carrier.

* Charges are limited to an established fee schedule
* Providers submit their charges to the workers’ compensation insurance carrier
* Payment is made directly to the healthcare provider

**progress report**

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A document filed by the physician in state workers’ compensation cases when a patient’s medical condition or disability changes; also known as a supplemental report.

**first report of injury**

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A document filed in state workers’ compensation cases that contains the employer’s name and address, employee’s supervisor, date and time of accident, geographic location of injury, and patient’s description of what happened.

> filed by employer or physician

**Admission of Liability**

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Carrier’s determination that an employer is responsible for an employee’s claim under workers’ compensation.

**Notice of Contest**

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Carrier’s notification of determination to deny liability for an employee’s workers’ compensation claim.

**physician of record**

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Provider under a workers’ compensation claim who first treats the patient and assesses the level of disability.

Termination of compensation benefits

Temporary partial and temporary total disability benefits ceases when one of the following occurs with employee:

* Given physician’s release authorizing a return to regular job
* Offered a different job by employed (not the same) and either returns to work or refuses to accept new assignment
* Has exhausted maximum workers’ compensation benefits for the injury or illness
* Cannot work due to circumstances other than the work-related injury (eg. injured in car accident → in an unrelated disability)
* Does not cooperate with request for medical examination
* Has died (benefits go to survivors)

Billing & claim management

Appointment for injury related to work, info to be collected from pt:

* Date of injury
* Workers’ compensation carrier
* Employer at time of injury
* Patient’s other insurance

Medical insurance specialists contacts the workers’ compensation carrier for authorization to treat pt before initial visit. PMP (primary management program) captures workers’ compensation and injury-related info when pt injury case record is created & updated.

Providers must accept payment from the insurance carrier as payment in full.

The medical insurance specialist contacts the workers' compensation carrier for authorization to treat the patient before the initial visit.

> some plans use HIPAA 847 or CMA-1500 and other plans have their own claim forms

General guidelines:

* Providers must accept payment coming from insurance carrier as payment in full; pt/employees may not be billed for any medical expenses
* Separate file must be made when provider treats someone who is already a pt of the practice. Info in the pt regular medical record (non-workers’ compensation) must not be released to the insurance carrier) -- two separate medical records.
* Pt signature is not required on any billing forms
* Workers’ compensation claim # to be included on all forms/correspondence
* Use 8-digit format when reporting dates eg. date last worked

Appeals

Individuals may appeal workers’ compensation decisions.

Appeal process: request mediation (impartial individual who works with both parties to obtain satisfactory resolution → mediation efforts on behalf of the injured employee fail → hearing may be requested (formal legal proceeding) → judge listens to both sides and renders decision (order) → employee not satisfied with judge decision, claim appealed at higher levels eg. workers’ compensation appeals board followed by perhaps state supreme court.

Disability compensation program

Plan providing partial reimbursement for lost income when disability prevents one from working.

Disability compensation and automotive insurance programs

Disability compensation programs ~~don’t reimburse policyholders for healthcare charge,~~ instead provided partial reimbursement for lost income when disability prevents one from working. Benefits = cash payment. To receive compensation under disability program = one’s medical condition must be documented in record, serving as substantiation for disability benefits.

**disability compensation program**

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A plan that reimburses the insured for lost income when the insured cannot work because of an illness or injury, whether or not it is work related.

FERS

The government program for disability benefits for federal employees

FICA

Law authorizing employee payroll deductions for SSDI

**Social Security Disability Insurance (SSDI)**

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The federal disability compensation program for (lost wages due to disability) salaried and hourly wage earners, self-employed people who pay a special tax 10 yrs, and widows, widowers, and minor children with disabilities whose deceased spouse/parent would qualify for Social Security benefits if alive.

How long must the period physical or mental impairment under the definition of disability used by SSDI last = A continuous period of not less than twelve months. 5mnth waiting period after SSDI has been filed before payments begin.

__categories of disability:__

* Cases in which individuals cannot return to their former positions and cannot obtain employment in the local area
* Presumptive legal disability, which includes cases that are specifically listed in the SSDI manual
* Cases with more than one condition that together meet the disability standards

__eligibility:__

A disabled widow or widower fifty years or older whose deceased spouse paid into Social Security for at least ten years

An employee who is blind or whose vision cannot be corrected to more than 20/200, even with a corrective lens

A divorced disabled individual fifty years or older whose deceased spouse paid into Social Security for at least ten years.

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FICA - payroll deductions used to partially fund SSDI

**Supplemental Security Income (SSI)**

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Government program that helps pay living expenses for low-income older people and those who are blind or have disabilities.

Children under age eighteen who are disabled or blind and in need may qualify.

A person whose income and resources are under certain limits can qualify even if he or she has never worked or paid taxes under FICA.

Preparing disability reports

In disability cases, inadequate or incomplete medical records may result in denial of a disability claim

Private Programs

Employers are not required to provide disability insurance.

Individuals may purchase disability policies from private insurance carriers.

Federal and state government employees are eligible for a public disability program.

Veterans programs

Veteran's Pension Program

Veteran's Compensation Program

eligibility: The disabled veteran will not be able to obtain gainful employment.

The disability must be permanent and total.

The disability must be service related.

**automobile insurance policy**

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A contract between an insurance company and an individual under which the individual pays a premium in exchange for coverage of specified car-related financial losses.

Automobile insurance

Coverage:

* No-fault coverage/personal injury protection/medical payments/medpay (motor vehicle) - covers the driver and passengers of a policyholder’s vehicle. PIP, is insurance coverage for medical expenses and other expenses related to an MVA
* Collision - covers dmg to the policyholder’s vehicle resulting from a collision
* Comprehensive - covers dmg to the policyholder’s vehicle that don’t involve a collision with another vehicle
* Liability - covers dmgs to the policyholder causes to someone else’s body/property

Treating pts covered under automobile insurance policy may require medical specialist to perform specific actions to receive full payment:

* coordinating claims w insurance CO providing pt vehicle insurance policy + verifying the benefits & obtaining preauthorization prior to treatment (if possible)
* Ruling out coverage under workers’ compensation by asking if pt MVA was work related
* lien -- written legal claims on property to secure payment of debt -- to ensure payment
* Filling out boxes 10b and 14 on the CMS-1500 to indicate pt is MVA related and the date + accident claim #
* Talking with pt attorney to stay informed, preparing for possible settlement of claim
* Making copy of pt health insurance card to provide practice the alt source of reimbursement in the event the vehicle insurance carrier doesn’t pay for a claim or doesn’t fully cover

Disability claim

report to include:

* Medical history
* Subjective complaints
* Objective findings
* Diagnostic test results
* Diagnosis
* Treatment
* Description of patient’s ability to perform work-related activities

Subrogation

Action by payer to recoup expenses for a claim it paid when another party should have been responsible for paying at least a portion of that claim.

primary payment responsibility on the part of workers’ compensation, liability insurance (self-insurance included), no-fault insurance is generally set according to settlements, judgements, awards, or other payments. There programs “settle” with pt, long after accident or situation that caused injury.