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Workers Comp Terms

Module 5
STUDY
PLAY
adjudication
judicial dispute resolution process in which an appeal board makes a final determination
arbitration
dispute-resolution process in which a final determination is made by an impartial person who may
not have judicial powers.
Federal Black Lung Program
enacted in 1969 as part of Black Lung Benefits Act; provides medical treatment and other benefits for respiratory conditions related to former employment in the nations coal mines.
First Report Of Injury
workers' compensation form completed when the patient first seeks treatment for a work-related illness
or injury.
Material Safety Data Sheet ( MSDS )
contains information about chemical and hazardous substances used on site.
Merchant Marine Act ( Jones Act )
not a workers' compensation statue, but provides seaman with the same protection from employer
negligence, as FELA provides railroad workers.
permanent disability
refers to an illness or injured employee's diminished capacity to return to work
survivor benefits
claim that provides death benefits to eligible dependents, which are calculated according to the
employee's earning capacity at the time of illness or injury.
temporary disability
claim that covers healthcare treatment for illness and injuries, as well as payment for lost wages.
vocational rehabilitation
claim that covers expenses for vocational retraining for both temporary and permanent disability cases
The Office of Workers' Compensation Programs ( OWCP)
administers programs that provide medical treatment, vocational rehabilitation, and wage replacement benefits
The Energy Employees Occupational Illness Compensation Program
began providing benefits to eligible employees and former employees of the Department of Energy in 2001
The Federal Black Lung Program
was enacted in 1969 to provide medical treatment and other benefits for respiratory conditions related to
persons formerly employed in the nation's coal mines.
The Federal Employee's Compensation Act ( FECA )
program provides workers' compensation to all federal and postal workers throughout the world for employment-related injuries and occupational diseases, and includes medical and vocational rehabilitation, payment for medical care and wage replacement.
The Longshore and Harbor Workers' Compensation Program
covers private-industry workers who are engaged in extracting natural resources from the outer continental
shelf
Material Safety Data Sheets contain information about
chemical and hazardous substances used on site
Workers Compensation Board
responsible for administering workers' compensation laws
adjudication
the judicial dispute resolution process in which an appeals board makes a final determination
First Report of Injury
is completed when the patient initially seeks treatment for a work- related illness or injury
The Division of Coal Mine Workers' Compensation administers and processes
claims for the
Federal Black Lung Program
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
if the employee was not negligent in performing assigned duties
The medical term for black lung is
pneumoconiosis
The Mine Safety and Health Administration (MSHA) is similar in purpose and intent to the
Occupational Safety and Health Administration (OSHA)
Material Safety Data Sheets (MSDS) contain data regarding
chemical and hazardous substances used at a worksite
How long must records of employee vaccinations and accidental exposure
incidents be retained?
20 years
The Federal Employment Liability Act (FELA) and the Merchant Marine Act were designed
to
provide employees with protection from employer negligence
Which agency is responsible for handling appeals for denied workers' compensation claims
State Workers' Compensation Commission
Workers compensation survivor benefits are calculated according to the
employee's earning capacity at the time of illness or injury
A patient was treated by his primary care physician on 01/25/YYYY for a wrist fracture that
occurred on the job. On 02/02/YYYY, the patient was evaluated for symptoms of severe high blood pressure and a recheck of the wrist fracture. Where should the provider document treatment from the visit on 02/02/YYYY?
Only the fracture recheck is to be recorded in the workers' compensation record
The First Report of Injury form is completed by the
provider
The treating physicians personal signature is required
on all original reports and photocopies
After the claim has been acknowledged, the information that must be included on all correspondence to the employer, payer, and the Commission Board is the
file/case number assigned to the claim
When an appeals board renders a final determination on a claim, this is known as
adjudication
Which of the following can be a designated state workers' compensation fiscal agent?
a private, commercial insurance company
Workers compensation plans allow an employer to set aside a state-mandated
percentage of capital funds to cover employee compensation and benefits are
self-insurance plans
If a patient fails to alert the provider that an injury was work-related, then changes his mind later and tries to receive workers' compensation benefits, the claim will most likely be
denied by the workers' compensation payer, and the patient will have to appeal
Which box is marked in Block 6 workers' compensation CMS-1500 claims?
OTHER
What is entered in Block 17a of the workers compensation CMS-1500 claim?
nothing ; the block is left blank
How do workers compensation laws protect the employer?
by limiting the award an injured employee can recover from an employer and by limiting the liability of
coworkers in most incidents.
5 classifications of workers' compensation cases?
medical treatment, temporary disability, permanent disability, vocational rehabilitation, and survivor
benefits.
3 circumstances qualify an employee for workers compensation benefits?
1) injured while working within the scope of the job description, 2) injured while performing a service
required by the employer, 3) succumbs to a disorder that can be directly linked to employment ( asbestosis or mercury poisoning ) * some states have protection for jobs considered extremely stressful; stress would be the qualifying reason.
Time limit for filing First Report of Injury form?
Varies from 24 hours to 14 calendar days; depending on state requirements. It is best to complete immediately as not to forget and miss the qualifying time limits.
Why not obtain a signature from First Report of Injury or CMS-1500 claim form?
There is no patient signature line on this form and the law states when a patient requests treatment for a
work related injury or disorder, the patient has given consent for the filing of compensation claims and reports.
Claims for treatment provided to injured employees on worker's compensation cases
should be sent to the
employer-designated compensation payer
Employers with sufficient capital can
self-insure
Which is the special report that is completed and submitted to the workers' compensation
payer when the patient first seeks treatment for a work-related injury?
First Report of Injury form
The death benefits paid to eligible dependents are called _______ benefits.
survivor
Workers' compensation law states that when a patient requests treatment for a work-related
injury, the patient has given consent for
the filing of compensation claims and reports.
Protection from railroad employer negligence is covered under the
FELA - Federal Employment Liability Act
Workers' compensation insurance also provides payments to qualified
dependents of workers who die from a compensable illness or injury.
The State Insurance Fund must offer
offer workers' compensation insurance to any employer requesting it.
The Federal Black Lung Program covers
coal miners who are totally disabled due to pneumoconiosis.
The Date of Current ______ must be completed in block 14 of the CMS-1500 claim.
Injury
What requires employers to maintain workers' compensation coverage?
Federal and state laws
What are the four programs of the Office of Workers' Compensation Programs
1) Energy Employee's Occupational Illness Compensation Program

2) Federal Black Lung Program

3) Federal Employee's Compensation Act ( FECA) Program

4) Longshore and Harbor Workers' Compensation Program
The Department of Labor also manages programs designed to prevent work-related
injuries and illnesses, they include?
Mine and Safety Health Administration ( MSHA )
Occupational Safety and Health Administration
(OSHA)
Other federal programs include:
Federal Employment Liability Act (FELA)
Merchant Marine Act ( Jones Act )
Workers Compensation Board or Commission is:
a state agency responsible for administering workers' compensation laws and handling appeals for
denied claims or cases in which a worker feels compensation was too low
First Report of Injury ( 4 copies go to )
1) State Workers' Compensation Board/Commission

2) Employer - designated compensation payer

3) Ill or injured party's employer

4) Patients' work related injury chart
black lung disease
pneumoconiosis
When patient tells you this was a work related injury, you must obtain the following info:
Name / address of present employer,
Name of immediate supervisor,
Date & time of the accident or onset of disease
Site where injury occurred
Patients' description of the onset of the disorder; if patient is claiming injury due to hazardous chemicals
or compounds, these should be included in the patient's description of the problem
-In addition the patients' employer must be contacted to obtain the name and mailing address of the compensation payer
-ask for a faxed confirmation from the employer of the worker with the on the job injury. If the employer disputes the legitimacy of the claim, you should still file the First Report of Injury. The employer must also file an injury report with the compensation commission/board.
purposeful intent
fraud
taking advantage of a situation
abuse
example of employer fraud
committed by an employer who misrepresents payroll amounts or employed classifications
example of employee fraud
committed when an employee lies or provides false information or a false statement, intentionally fails to
report income from work, or willfully misrepresents a physical condition to obtain benefits from the state compensation fund
provider fraud
committed by healthcare providers and attorneys who inflate their bills for services or bill for treatment of
non-work related illnesses and injuries
Progress reports include:
patients name & compensation file/case number
treatment and progress report
work status at the present time
statement of further treatment needed
estimate of the future status with regard to work or permanent loss or disability
copies of substantiating x-ray, laboratory, or consultation reports
Progress reports copies go to
one copy to compensation payer
one copy to the patient file
What do you do if an injured worker presents for the first visit without a written or personal
referral from the employer
contact the employer immediately
what if treatment is sought in another state than where the injury occurred
contact the workers' compensation board/commission of the state where the work related injury occurred
The Office of Workers' Compensation Programs administers provide
medical treatment, vocational rehabilitation, wage replacement benefits
The Energy Employees Occupational Illness and Compensation Program began providing
benefits to eligible employees and former employees of the Department of Energy in
2001
Which is responsible for administering workers' compensation laws?
Workers' Compensation Board