copyright © 2008 delmar learning. all rights reserved. chapter 17 workers’ compensation
TRANSCRIPT
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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.
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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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Federal Workers’ Compensation Programs
• 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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Federal Workers’ Compensation Programs
• Department of Labor also designed these programs to prevent work-related injuries and illnesses:– Mine Safety and Health Administration – Occupational Safety and Health
Administration
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Other Federal Programs
• Federal Employment Liability Act
• Merchant Marine Act
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Energy Employees OccupationalIllness Compensation Program
• Provides benefits to employees that qualify under the Department of Energy
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Federal Black Lung Program
• Provides medical treatment and other benefits for respiratory conditions related to former employment in the nation’s coal mines.
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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.
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Longshore and Harbor Workers’ Compensation Program
• Provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers.
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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
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Federal Employment Liability Act
• Provides railroad employees with protection from employer negligence
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Merchant Marine Act
• Not a workers’ compensation statute– Provides seamen with the same protection
from employer negligence
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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 Workers’ Compensation Program
• 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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State Workers’ Compensation Program
• Commercial workers’ compensation insurance: – Employers are permitted to purchase
policies from commercial insurance companies
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State Workers’ Compensation Program
• Combination programs– Employers in some states are allowed to
choose a combination of any of the above to comply with workers’ compensation coverage
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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
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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
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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.