Chapter 14 Workers' Compensation Flashcards
Workers’ Compensation
Workers’ Compensation is a benefit program that requires an employer to pay, or provide insurance to pay, for the lost wages and medical expenses of an employee who is injured on the job.
Workers’ Compensation
Independent contractors are not entitled to workers’ compensation benefits, and in some states domestic workers and agricultural workers are excluded or only partially covered.
Purpose and Scope
*Workers’ compensation is considered a no-fault insurance program, meaning an injured
*Employee will receive benefits regardless of who was at fault (the employer, the employee, a patient, etc.
Segregation of Documentation
Workers’ compensation insurance payers and the state compensation boards/commissions are allowed by law to review only treatment data and history pertaining to the patient’s on-the-job injury.
Segregation of Documentation
Maintaining separate charts for workers’ compensation injuries is essential to ensure the correct information is being submitted.
HIPAA Privacy Rule does
not apply to entities that are either workers’ compensation insurers, workers’ compensation administrative agencies, or employers, except to the extent they may otherwise be covered entities.
HIPAA Privacy Rule does
Providers who treat patients for workers’ compensation injuries or illness must create a separate chart for documentation of the work-related injury and treatment.
BILLING TIP
It is important to keep the work related and non-work-related documentation separate. If paper charts are utilized, having a separate chart for the work-related injury is required. Make the chart a different color to make it easy to identify. If EHR/EMR is used, open a separate progress note and identify it in a way that will make it easy to recognize the work-related injury.
Occupational Safety & Health Administration (OSHA)
This department was created to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance.
Those not covered by OSHA include
*self-employed,
*Immediate family members of farm employers that do not employ outside workers,
*and injuries covered by another federal agency (for example, the Coast Guard).
According to OSHA,
the healthcare and social assistance industry have more work-related injuries and illness than any other sector.
Orderlies …
are now called
Patient Care Assistant and CNA
Healthcare workers include medical staff, maintenance, housekeeping, food service, laundry, and administrative staff. Healthcare workers face many serious safety and health hazards.
*These hazards include bloodborne pathogens and biological hazards,
*potential chemical and drug exposures, waste anesthetic gas exposures, respiratory hazards,
*ergonomic hazards from lifting and repetitive tasks, laser hazards, workplace violence,
*hazards associated with laboratories, and radioactive material and X-ray hazards.
Coverage and Provider Reimbursement
To qualify for workers’ compensation, an employee must be injured while working within the scope of their job description, injured while performing services required by the employer, or contract an illness that can be directly connected to employment.
Payment of Premiums
Federal and state laws require employers to maintain workers’ compensation coverage.
Federal employees are covered under one of the federal workers’ compensation programs.
Energy Employees Occupational Illness Compensation Program (EEOICP)
Provides lump-sum compensation and health benefits for eligible Department of Energy nuclear weapons workers (including employees, former employees, contractors, and subcontractors) injured on the job.
Federal Employees’ Compensation Program—The Federal Employees’ Compensation Act (FECA) provides workers’ compensation coverage to three million federal and postal workers around the world for employment-related injuries and occupational diseases.
The Division of Federal Employees’ Compensation (DFEC) adjudicates new claims for benefits and manages ongoing cases.
All medical authorizations and claims processing are handled by a contractor, which at this writing is ACS.
ACS provides an online tool at https://www.dol.gov/owcp/dfec/regs/compliance/WebPortal.htm where injured workers, medical providers, or employing agencies can:
*check eligibility
*check authorization
*check bill payment
Section Review 14.1
Under Workers’ Compensation, when is a worker covered for an injury that occurred on-the-job?
Answer: C. They are covered regardless of who is at fault.
Which program covers postal workers for employment related injuries?
Answer: B. Federal Employees’ Compensation Program
Can an employer require an employee to pay a portion of the insurance premiums for the workers’ compensation coverage? Why or why not?
Answer: D. No, the employer is required by law to pay the premiums for coverage.
A patient presents to be seen with chronic beryllium disease that he incurred while under government employment. What coverage would apply to him?
Answer: A. Part B Energy Employees Occupational Illness Compensation Program
According to OSHA, who has the highest rate of work-related musculoskeletal disorders?
Answer: C. Nurses’ aides
Longshore and Harbor Workers’ Compensation Program (LHWCP)—
The Longshore and Harbor Workers’ Compensation Program provides workers’ compensation benefits to most waterfront workers and contractors working overseas for the U.S. government.
The Federal Black Lung Program
*is an act providing compensation and medical coverage for treatment to coal miners who are totally disabled by pneumoconiosis arising out of coal mine employment,
*and to survivors of coal miners whose deaths are attributable to the disease
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Individuals injured on the job while employed by private companies or state and local government agencies would be covered by insurance payers through their state workers’ compensation board.
The workers’ compensation law is governed by each state.
State Insurance Fund—
An agency that provides workers’ compensation insurance coverage to private and public employers and acts as an agent in state workers’ compensation cases involving state employees.
Self-Insurance Plans—
Employers with adequate capital to qualify can self-insure.
Commercial Workers’ Compensation Insurance—
Commercial insurance companies that meet state mandates for workers’ compensation coverage can offer policies for employers to purchase.
Combination Programs—
In some states, employers can choose a combination of any of the above to comply with workers’ compensation coverage requirements.
Reimbursement Requirements for Providers
Providers are required to accept reimbursement from workers’ compensation payers as payment in full.
Claims Completion
*When an employee is injured on the job, a claim is filed with the employer’s workers’ compensation carrier.
*Once a claim is filed, the date of injury/illness is established, and the employee is assigned a claim number.
*This claim number acts as the equivalent of an insurance ID number when filing medical claims for reimbursement
The claim will be submitted to the workers’ compensation payer in paper format using a CMS 1500 claim form.
A First Report of Injury form and the progress note for the encounter must also be submitted with the paper claim.
The filing deadline for the first report of injury is determined by state law.
The deadline for filing of the claim for services will vary by payer.
What must be submitted to the workers’ compensation payer after an initial employee injury visit?
Answer: D. First Report of Injury form, CMS-1500 claim form, and office encounter note
A 70-year-old patient with complex pneumoconiosis presents after a fall. X-rays are taken and are negative for fracture. The patient gives both a Medicare card and a Federal Black Lung ID card. How should this claim be billed?
Answer: C. Medicare only
Rationale: Federal Black Lung only pays claims that relate to conditions from the pneumoconiosis. This patient fell and had X-rays that are not related to his lung condition. Therefore, Medicare would be the only payer billed for this visit.
What type of state workers’ compensation coverage allows an employer to set aside money to cover medical expenses and other related benefits for its employees?
Answer: B. Self-insurance plans
What kind of workers are covered under the Longshore and Harbor Workers’ Compensation Program?
Answer: C. i and iv
Rationale: The LHWCA covers workers in traditional maritime occupations, such as longshore workers, shipbuilders, ship-repairers, and harbor construction workers. The LHWCA specifically excludes seamen, employees of the U.S. government or of any state or foreign government, employees whose injuries were caused solely by their intoxication, and employees whose injuries were due to their own willful intention to harm themselves or others.
What is the timely filing limit for claims for workers’ compensation services?
Answer: B. Will vary by payer
Combination Programs
In some states, employers can choose a combination of coverage options (state, commercial, or self) to comply with workers’ compensation coverage requirements.
Energy Employees Occupational Illness Compensation Program
Provides lump sum compensation and health benefits for eligible Department of Energy nuclear weapons workers injured on the job.
Federal Black Lung Program
An act which provides compensation and medical coverage for treatment to coal miners
Longshore and Harbor Workers’ Compensation Program—
waterfront workers and contractors working overseas for the U.S. government.
OSHA
Occupational Safety and Health
