Workers' Compensation

Workers' Compensation

1. Federal Compensation Laws

   • Applies to: 1. Miners, Maritime Workers, and those who work for the government
   • Coverage
     • Workmen's Comp Law of the District of Columbia
       • Federal Coal Mine Health and Safety Act
         • Federal Employees' Comp Act
           • Longshoremen's and Harbor Workers' Comp Act

2. State Compensation Laws

   • Applies to employers and employees within each state
     • Self Insurance
       • Employer self insures employees for a pre-determined amount
         • Pays for medical expenses instead of insurance premiums
         • Prohibited from putting lifetime caps
       • Covered by ERISA
     • It's illegal for an employer to fail to report a work related accident
     • Employer's Liability Insurance
     • Compulsory
       • required to accept provisions
     • Elective
       • May accept or reject
   • Minors are covered
   • Interstate Laws
     • Most comp laws are EXTRATERRITORIAL
       • Second- Injury Fund
         • Pre-existing injury combines with second injury to product greater disability
           • Encourages hiring of the physcially handicapped
           • Allocate more equitably the costs of providing benefits to such employees
   • Each state has minimum # of employees
   • 5 Benefits
     • Medical Treatment
     • Permanent disability indemnity
       • May be weekly or monthly payments
       • Death benefits for survivors
         • Rehab benefits

3. Old name was Workmens' Compensation

4. no liability for employer ( unless gross negligence)

5. Enables Employee to be quickly compensated for:

   • Loss of Wages
   • Medical Expenses
   • Permanent Disability

6. Not required to comply with HIPAA

7. PURPOSE

   • Provide best medical care to ensure prompt return to work
     • Provide income to the injured and dependents
       • Provide a single remedy to reduce court costs
         • Relive charities of financial drains
           • Eliminate attorney fees
             • Encourage max. employer interest
               • Promote Study of causes of accidents and reduce preventables

8. Eligibility

   • Private Business Employees
     • State Employees
       • Federal Employees

9. Industrial Accident

   • unplanned and unexpected happening traceable to a definite time and place

10. Occupational Illness

    • abnormal condition or disorder caused by exposure to environmental factors associated with work

11. Types of State Claims

    • Nondisability claim
      • Involves minor injury and employee is able to continue working. Doesn't require weekly TD payments
    • Temporary Disability Claim
      • occurs when a worker has a work related injury and is unable to perform the duties for a specific period of time
      • Time period can extend from date of injury until the worker returns to full duty, modified work, or ratable residual disability that's permanent and stationary
      • Vocational Rehab
        • retraining, education, job guidance, and placement to assist an injured individual in finding work before TD benefits expire.
      • Work Hardening
        • individualized program using simulated or real work tasks to build up strength
      • Ergonomics
        • evaluation of the work site is performed, and modifications may be instituted to the job 
    • Permanent Disability Claim
      • patient or injured party is usually on TD benefits for a time and then concludes that he or she is unable to return to former occupation
      • Each patient is rated according to severity of injury, age of injured person, and patient's occupation
      • Physician's final report just say permanent and stationary
        • Evaluation and Management (E/M) modifier may be used.
      • Compromise and Release
        • agreement between the injured party and insurance company on a total sum
        • Delays
          • Unanswered questions or incomplete answers
          • Vague terminology
          • Omitted signatures
          • Incorrect billing by physician's office
          • .Inadequate progress reports
      • Rating
        • final determination of issues involving settlement of industrial accident is known as adjudication
        • Physician renders a professional opinion on whether the individual has temporary or PD
        • May be rated by using a scheduled or nonscheduled injury award system
        • Appeals
          • by petition to the Worker's Comp Appeals Board or Industrial Accident Commision

12. Fraud and Abuse

    • Physicians are responsible for determining legitimacy