1 Workers Compensation and Disability Chapter 13 © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

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