1 workers compensation and disability chapter 13 © 2010 the mcgraw-hill companies, inc. all rights...
TRANSCRIPT
1
Workers’ Compensation and Disability
Chapter 13
© 2010 The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 13 2
Learning OutcomesAfter studying this chapter, you should be able to:13.1 List the four federal workers' compensation
plans.
13.2 Describe the two types of workers' compensation benefits that are offered by states.
13.3 List the criteria an injury must meet to be considered a covered injury or illness.
13.4 List the five classifications of work-related injuries.
Chapter 13 3
Learning Outcomes (Continued)
13.5 List three responsibilities of the physician of record in a workers' compensation case.
13.6 Explain the difference between workers' compensation insurance and disability compensation programs.
13.7 Explain the difference between Social Security Disability Insurance (SSDI)
and Supplemental Security Income (SSI).
Chapter 13 4
Key Terms• Admission of
Liability• Disability
compensation programs
• Federal Employees’ Compensation Act (FECA)
• Federal Insurance Contribution Act (FICA)
• Final report• First report of
injury• Independent
medical examination (IME)
• Notice of Contest• Occupational
diseases or illnesses
Chapter 13 5
Key Terms (Continued)
• Occupational Safety and Health Administration (OSHA)
• Office of Workers' Compensation Programs (OWCP)
• Physician of record
• Progress report
• Social Security Disability Insurance (SSDI)
• Supplemental Security Income (SSI)
• Vocational rehabilitation
Chapter 13 6
Workers’ Compensation
• Workers’ compensation was developed to benefit both the employer and the employee.
• Employees receive compensation for injuries received while on the job.
• Employers are protected against liability for employees’ injuries.
Chapter 13 7
Occupational Safety and Health Administration
• OSHA protects workers from health and safety risks on the job
• Employees may file complaints directly with OSHA
Chapter 13 8
Federal Workers’ Compensation Plans
• Federal Employees’ Compensation Program• Federal Black Lung Program• Energy Employees Occupational
Illness Compensation Program• Longshore and Harbor Workers’
Compensation Program
Civilian employees of federal agenciesare covered under these programs
Chapter 13 9
Federal Workers’ Compensation Plans
• Federal Employees’ Compensation Program
• Federal Black Lung Program
• Energy Employees OccupationalIllness Compensation Program
• Longshore and Harbor Workers’ Compensation Program
Provides FECA benefits
Chapter 13 10
Federal Workers’ Compensation Plans
• Federal Employees’ Compensation Program
• Federal Black Lung Program
• Energy Employees OccupationalIllness Compensation Program
• Longshore and Harbor Workers’ Compensation Program
For individuals working in coal mines
Chapter 13 11
Federal Workers’ Compensation Plans
• Federal Employees’ Compensation Program• Federal Black Lung Program• Energy Employees Occupational
Illness Compensation Program• Longshore and Harbor Workers’
Compensation Program
For workers who have developed cancer and other diseases while working at atomic
weapons facilities
Chapter 13 12
Federal Workers’ Compensation Plans
• Federal Employees’ Compensation Program• Federal Black Lung Program• Energy Employees Occupational
Illness Compensation Program
• Longshore and Harbor Workers’ Compensation Program
For workers in the maritime field
These plans are administered by theOffice of Workers’ Compensation Programs
(OWCP) of the US Department of Labor
Chapter 13 13
State Workers’ Compensation Plans
• Each state
– administers its own workers’ compensation program
– has coverage that may vary from other states
Chapter 13 14
State Workers’ Compensation Plans
• Employers may purchase or obtain workers’ compensation insurance from
– State workers’ compensation fund
– Private insurance company
– Directly, through a self-insured fund
Chapter 13 15
State Workers’ Compensation Plans
Two types of workers’ compensation benefits include:
• Medical Expenses– Pays medical expenses for work related
injuries or illnesses
• Lost Wages– Pays for lost wages while the worker is
unable to return to work
Chapter 13 16
Covered Injuries and Illnesses
Covered injuries or illnesses must:
• Result in injury or death
• Occur by accident
• Arise out of employment
• Occur during the course of employment
Chapter 13 17
Exclusions to Covered Injuries and Illnesses
• Employee intoxication led to the injury
• Injury was intentionally self-inflicted
• Employee violated the law
• Employee failed to use safety equipment
• Employee failed to obey safety procedures
Chapter 13 18
Exclusions to Covered Injuries and Illnesses
• Employee also receives Social Security disability benefits
• Employee receives unemployment insurance
• Employee receives an employer-paid pension or disability benefit
Chapter 13 19
Classifications of Injuries
• Injury without disability
• Injury with temporary disability
• Injury with permanent disability
• Injury requiring vocational rehabilitation
• Injury resulting in death
Chapter 13 20
Workers’ Compensation Terminology
• Terminology is agreed upon by state compensation commissions and carriers
• Leads to a common understanding of patient’s condition
• Defines:– Pain levels
– Disability levels for heart disease, pulmonary dysfunction, abdominal weakness, or spinal injuries
– Disability levels due to lower extremity injuries
Chapter 13 21
Workers’ Compensation and the HIPAA Privacy Rule
• One of few times a provider may disclose patient’s PHI to an employer without patient’s authorization
• Most states also allow claims adjusters and employers unrestricted access to workers’ compensation files
Chapter 13 22
Claim ProcessPhysician Responsibility
The physician who first treats the injured or ill employee is known as the
physician of record
Chapter 13 23
Physician Responsibility
The physician of record is responsible for
• Treating the injured or ill worker
• Filing progress reports
• Determining the percentage of disability
• Determining the return to work date
Chapter 13 24
First ReportFirst Report of Injury or Illness:• Prepared by provider
– Dates and treatments– Patient’s history and description of injury/illness– Name and address of employer and supervisor– Detailed description of physical findings, results of
x-rays, diagnostic tests– Diagnosis and clinical treatment– Physician’s opinion of relationship between the
work environment and the injury/illness and how physician arrived at that opinion
• Submitted ASAP• No patient signature required
Chapter 13 25
Progress Reports
• Progress or Supplemental Reports– Submitted by provider– Report changes in employee’s health status– Work status, ability to perform tasks,
anticipated additional treatment, and extent of loss/disability
• Final report– Submitted by provider when treatment is
completed
Chapter 13 26
Employer andInsurance Carrier Responsibility
• Employer or physician must file first report of injury within a certain time period (defined by state)
• Insurance carrier – Assigns a claim number to the case– Determines whether claim is eligible– Notifies employer
Chapter 13 27
Billing and Claim Management
• Worker’s compensation covers provider’s charges– Other coverage may begin when workers’
compensation benefits are exhausted
• Each state has its own forms and regulations
• Narrative reports may be required• HIPAA 837 or CMS-1500 is usually used
Chapter 13 28
Billing and Claim Management
• Establish a separate record for workers’ compensation cases– Cases are subject to review and court hearings
– Law allows review of only history and treatment records that pertain to work-related injury/illness
– No patient authorization is required to disclose the information to the appropriate party
• State-assigned case number should be used on all claims and reports
Chapter 13 29
Disability Compensation Programs
• Disability compensation programs provide payment for lost income due to injury or illness (mostly non-work related) – not medical expenses
• Federal, state, and private carriers– Eligibility and benefits vary– Convincing medical evidence that the
condition resulting from injury/illness satisfies the criteria in the program/policy
Chapter 13 30
Social Security Disability Insurance
(SSDI)
• A government disability program defined through Social Security Act
• Funded by workers’ payroll deductions and matching employer contributions
• Employee deductions are known as Federal Insurance Contribution Act (FICA) deductions
Chapter 13 31
Supplemental Security Income
(SSI)
• A welfare program
• Provides payments to individuals in need
– including aged, blind, and disabled individuals
• Eligibility is determined using nationwide standards
Chapter 13 32
Federal Employees Retirement System (FERS)
• Covers federal workers hired after 1984• Prior to 1984, covered by Civil Service
Retirement System (CSRS)• Consists of federal disability program
AND Social Security disability program– Each part has different eligibility rules– Person may qualify for one or both programs– If eligible for both, SSDI payment is reduced
by amount of FERS payment
Chapter 13 33
Veteran’s Compensation Program and Veteran’s Pension Program
• Certain veterans may qualify for both federal programs
• VCP provides coverage for individuals with permanent and total disability resulting from a service-related injury/illness– Disability must affect earning capacity
• VCP provides benefits for service-related permanent disability to those who are unable to obtain gainful employment
Chapter 13 34
Preparing Disability Reports
• Medical insurance specialists do not file claims; do provide physician’s medical report and medical records
• Includes:– Medical history– Clinical signs and symptoms– Diagnosis– Treatment plan– Prognosis– Patient’s ability to perform work-related functions– Results of test, with copies of reportsPossible CPT codes: 99080 + E/M or 99455 or 99456