ch 17

Introduction Workers Comp
federal and state laws require employers to maintain workers compensation coverage to meet minimum standard, covering a majority of employees for work related illnesses and injuries. ( as long as the employee was not negligent in performing the assigned duties)
Workers Compensation Laws
also protect employers and fellow workers by limiting the award an injured employee can recover from an employer and by eliminating the liability of co-workers in most accidents
Programs (Federal Works Comp)
The US Department of Labor's (DOL) Office of Workers Compensation Programs (OWCP) administers programs that provide wage-replacement benefits, medical treatment, vocational rehabilitation, and other benefits.
Four programs include
*Energy Employees Occupational Illness Compensation Program
*Federal Black Lung Program
*Federal Employees' Compensation Act (FECA) Program
*Longshore and Harbor Workers Compensation Program
The Department of Labor
also manages the following programs designed to prevent work related injuries or illnesses:
*Mine Safety and Health Administers (MHSA)
*Occupational Safety and Health Administration
*Federal Employment Liability Act (FELA)
*Merchant Marine Act (jones act)
Federal Black Lung Program
enacted in 1969 as part of the Black Lung Benefit s Act, provides medical treatment and other benefits for respiratory conditions related to former employment in the nations coal mines
monthly benefits checks are sent to coal miners (or thir eligible surviving dependents) who are totally disabled by pneumoconiosis (black lung disease) arising from their employment in or around the nations coal mines.
Federal agencies reimburse FECA for workers compensation expenses through an annual BUDGET CHARGEBACK PROCESS, which transfers funds from a responsible federal agencies budget
Federal Employees' Compensation Act Program (FECA)
is administered by the OWCP and provides compensation coverage to all federal and postal workers throughout the world for employment related injuries and occupational diseases.
The OWCP's Division of Federal Employees Compensation (DFEC) processes new claims for benefits to injured workers and survivors, and helps injured emloyees return to work when they are medically able to do so.
Longshore and Harbor Workers Compensation Program
Administered by the U.S. Department of Labor, provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers who are injured during the course of employment or suffer from diseases cause or worsened by conditions of employment.
The program also covers private-industry workers who are engaged in the extraction of natural resources from the outer continental shelf, employees of American defense bases, an those working under contract with the U.S government for defenses or public-works project outside the continental United States.
Occupational Safety & Health Administration Act of 1970
Created this act to protect employees against injuries from occupational hazards in the work place. OSHA and its state partners (aprx 2100 inspectors) established protective standards enforce those standards, and reach out to the employees and employees by providing technical assistance and consultation groups.
Comprehensive records odf all vaccinations administrated and any accidental exposure incidences (e.g needle sticks) must be retained for 20 yrs.
Federal Employment Liability Act
Is not a workers compensation statute, but it provides railroad employees with the protection from employer negligence, and makes railroads engaged in interstate commerce liable for injuries to employees if the rail road was negligent.
State Workers Compensation Programs
Workers compensation insurance provides weekly cash payments and reimburses healthcare cost for covered employees who develop a work - related illness or sustain an injury while on the job.
Workers compensation Board Or Commission
A state agency responsible for administrating workers compensation laws and handling appeals for denied claims or cases in which a worker feels compensation was too low.Also, administrates programs that provide wage replacements for injured workers.
State insurance (or compensation) Fund
a quasi-public agency that provides workers compensation ins coverage to private and public employees and acts as an agent in state workers compensation cases involving state employees.
Self Insurance Plan
employees with sufficient capital to quality can self insure, which means they are required to set aside a state mandated percentage of capital funds to cover medical expenses, wage compensation, and other benefits (e.g death benefit to an employees dependents) payable to employees who develop on the job illnesses an or incur injuries.
Eligibility for workers compensation coverage
The worker does not have to be physically on company property to qualify for workers compensation.
Classification of workers compensation cases
The injured employees healthcare provider determines the extent of disability: cash benefits are directly related to established disability classifications. Federal law mandates the following classification of workers compensation cases:
Cases Include
Medical Treatment
Temporary disability
Permanent disability
Vocational rehabilitation
Survivor benefits
Medical Treatment
Medical treatment claims are the easiest to process because they are filed for minor illness or injuries that are treated by a healthcare provider. In these cases, the employee continues to work or returns to work with in a few days.
Permanent disability
Schedule loss of use, in which employees has as loss of eyesight, hearing, or a part of body or its use. Compensation is limited to a certain # of weeks according to a schedule set by law.
Providers who treat established patients for work-related disorders should create a compensation file (separated from the established medical record).
Survivor Benefits
Claims provided death benefits to eligible dependents. These benefit amounts are calculated according to the employments earnings capacity at the time of illness or injury.
Special Handling of workers compensation cases
Providers are required to accept the workers compensation-allowable fee as payment in full for covered services rendered on cases involving on the job illnesses and injuries.
First Report of injury Form
Are completed by the provider (physician) when the patient forst seeks treatment for a work-related illness or injury. (fig 17-1) This report must be completed in quadruplicate with one copy of distributed to each of the following parties:
Parties include
State Workers Compensation Board / Commission
Employer-designed compensation payer
Ill or injured party's employer
Patients work-related injury chart
If the employer disputes the legitimacy of the claim, you should still file the First Report of Injury.
Employer Fraud
Committed by an employer who misrepresents payroll amounts or employee classification or who attempts to avoid higher insurance risk by transferring employees to a new business entity that is rated in a lower-risk category.
There is no patient signature line on this form. The law says that 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
The physician should should personally sign the original and all photocopies of these reports.
a judicial dispute resolution process in which an appeals board makes a final determination
a legal proceeding during which a party answers questions under oath.
Adjudication is different from arbitration, a dispute resolution process in which a final determination is made by an impartial person who may not have judicial powers.
progress reports
a detailed narrative progress/ supplemental report should be filed to document any significant change in the worker medical or disability status
wokrer compensation is sometimes mistakenly referred to by its previous name, workmans compensation. The name change occured years ago to reflect an increase in the number of woman in the hospital