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Claims Exams > Everything Else > Flashcards

Everything Else Flashcards

1
Q

Define Impairment

A

A permanent loss of use or function of a body part or system related to the compensable condition.

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2
Q

Define Compensation

A

Includes a benefits including medical servicers provided for a compensable injury to a subject worker

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3
Q

Define Permanent Partial Disability (PPD)

A

Permanent loss of use or function of a body part or system resulting from the compensable injury or disease or permanent impairment

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4
Q

Define Permanent Total disability (PTD)

A

Permanently unable to perform work in a suitable and gainful occupation

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5
Q

Define Objective Findings

A

Verifiable indications of injury or disease, including range of motion, atrophy, muscle strength and palpable and muscle spasm.

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6
Q

Why is it important to set reserves on a claim (5 things)

A
  1. Allows SAIF to estimate future liabilities
  2. Reserves are used set rate making and mod rating
  3. Calculate premium for retrospective
  4. Helps facilitate underwriting decision
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7
Q

What info is included on an acceptance?

A
  1. The condition being accepted (compensable conditions)
  2. Expedited Claim Services
  3. Is it disabling or NonDisabling
  4. Reimbursement to the worker for expenses
  5. How to submit a new or omitted condition.
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8
Q

Who determines impairment at the reconsideration level?

A

Medical Arbiter Physician or AP

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9
Q

What additional factoring is included in a PPD award

A

Rating of impairment as well as work disability

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10
Q

How many days do insurers have to appeal the Notice of Closure

A

7 days from the Notice of Closure

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11
Q

What is chronic condition impairment?

A

The worker is significantly limited in repetitive use of one ore more of the following body parts (spine, chest, shoulder, arm, hip, leg)

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12
Q

Define Palliative care

A

Medical services rendered to reduce or moderate temporarily the intensity of an otherwise stable condition

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13
Q

What is the 1st level of appeal on a NOC?

A

Reconsideration by the WCD

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14
Q

When can a claim be closed administratively?

A

Medical treatment for more than 30 days or a warning letter has been sent to seek treatment if no response after 14 days the claim can be closed.

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15
Q

What info is needed before closing a claim?

A
  1. Med Stat status
  2. Work release info (date of release)
  3. Actual work status
  4. Info about permanent impairment
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16
Q

What qualifies a claim for closure?

A

The date SAIF receives the final piece of medical info need to close a claim or 30 days from the last medical treatment received by the IW

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17
Q

Define Initial Claim

A

The first open period immediately following the original filing of OD or injury claim until the worker is declared med stat.

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18
Q

What is the purpose of the MCO

A

To help manage the medical services in a claim, to ensure the medical treatment is reasonable and necessary to get the worker back to work and close the claim.

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19
Q

What is the Last Injury Rule (LIR)

A

Last injury that contributed to the underlying condition.

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20
Q

Define Preexisting Condition

A

any injury or disease that contributes to a disability or need for treatment

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21
Q

What are examples of significant events that prompt review of reserves?

A

Change in time loss
Change in work release
Receipt of medical info (Surgery)
Claim closure
Request to re open, or accept a new, omitted condition
Passage of time without further treatment plan

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22
Q

When would vocational services end?

A

Suitably employed for more than 60 days
max services allowed
claim is settled by CDA
Worker fails to cooperate

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23
Q

Define a disabling injury

A

An injury that entitles the worker to compensation for disability or death

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24
Q

What 4 main conditions must an IW meet in order to qualify for vocational assistance?

A

Authorized to work in US
Not able to return to reg. work or other suitable work at EAI
Not suitably employed for more than 60 days
Has a substantial handicap

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25
Q

What issues are reviewed by the WCB

A

Administers rules related to hearings and litigation

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26
Q

When would you NOT approve a lump sum settlement?

A

The worker has not waived the right to appeal.
The award is not final
Pending a request for a hearing
The worker is enrolled in a vocational training program

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27
Q

What is a substantial handicap to employment

A

The worker lacks the knowledge, skills, and ability to make a suitable wage without assistance.

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28
Q

Define Work Disability

A

Separate factoring of impairment as modified by age, education and adaptability to perform the job at which the worker was injured.

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29
Q

Define Aggravation

A

Actual worsening of the compensable condition after the last award of compensation, which is established by medical evidence supported by objective findings

30
Q

Define Combined Condition

A

When an otherwise compensable injury combines with a qualified preexisting condition to cause or prolong the need for treatment

31
Q

Define Come Along Provider

A

AP is not in a MCO panel providers but will become a temporary provider to continue to treat the IW during the claim.

32
Q

Define Med Stat

A

No further improvement is expected with either treatment or the passage of time.

33
Q

When are Time loss payments not payable

A

If the IW has withdrawn from the workforce
Unable to verify the worker’s ability to work
Type B provider time frames have expired
Incarcerated

34
Q

How many days doe insures have to pay a PPD award granted by closer?

A

30 days from the mailing date of the notice of closure

35
Q

What is the legal standard for a consequential condition

A

Compensable injury is the major contributing cause of the consequential condition

36
Q

What is the legal standard for a combined condition

A

Major contributing cause of the combined conditions need for treatment

37
Q

What does the phrase “course and scope” mean?

A

Arising out of - causal relationship to work

In course of refers to time, place, and circumstances surrounding the accident

38
Q

What are two common settlements in a denied claim?

A

DCS - Disputed Claim Settlement

STip - rescinding the denial and accept the claim

39
Q

If worker is represented by an attorney, how many days do you need to provide discoverable documents?

A

14 days from request and every 30 days for 180 days.

40
Q

In what 4 area are we responsible for setting reserves?

A

Medical
Time Loss
PPD
Legal Cost

41
Q

How many days can a type B provider provide medical services?

A

60 days or 18 visits from the date of the first visit

42
Q

How many days can a type B authorize timeloss?

A

30 days from the date of the first visit

43
Q

How long can ER physician authorize time loss?

A

14 days from ER visit.

44
Q

How long can ANP provider medical services and authorize time loss?

A

180 days from the date of the first visit on the initial claim.

45
Q

Define Curative Care

A

care provided to stabilize a temporary and acute waxing and waning of symptoms.

46
Q

Who are Type B providers?

A

Chiropractor, Physician assistant, or a naturopathic physicians

47
Q

When would you pay the PPD award in a lump sum

A
  • Less than $6000

* More and the worker requests it

48
Q

How would you describe new claims management

A

During the deferred status, the adjuster determines whether it is an injury or an OD and is it covered under workers’ comp insurance. Needs to be determined within 60 days.

49
Q

Who has the burden of proof in a back up denial

A

The insurer.

50
Q

Who receives the acceptance?

A 
The Worker
The employer
The attorney (if necessary)
The provider
The MCO 
WCD
51
Q

Who receives the denial?

A

The worker, the employer, the attorney, the providers, WCD, private health insurance.

52
Q

What types of things can a worker request reimbursement for?

A

Meals, lodging, private or public transportation, prescriptions

53
Q

What is the closure qualification date?

A

The last date that SAIF receives the final piece of medical information needed to close the claim.

54
Q

What questions should you ask when determining whether or not to pay for palliative care?

A
  1. Was the care contemplated at the time of closure
  2. Is the worker currently employed?
  3. Is the care palliative or curative?
  4. Does the documentation explain how the care is related to the accepted condition?
  5. Specific time frames, frequency, duration and who
55
Q

State the Claims tenet around financial stability

A

Claims employees will guarantee current and future benefits by managing reserves, administering compensable benefits, and aggressively managing litigation to ensure corporate financial stability

56
Q

State the claims tenet around Climate

A

Claims employees will be mindful of the changing business climate and workers comp landscape to positively influence a culture of change that anticipates the future needs of Oregon workforce and economy.

57
Q

State the settlement tenet around Value

A

The settlement value of a claim is the present value of probably claim benefits discounted by the uncertainty of entitlement?

58
Q

State the settlement tenet around Litigation

A

Employees have a responsibility for anticipating and preparing for litigation and for considering settlement only after adequate preparation

59
Q

State the settlement tenet around DCS

A

DCS should be employed where issues lack clarity as to compensability or benefit entitlement.

60
Q

What could you do if a worker fails to attend an IME?

A

Request suspension of benefits from WCD or Request a penalty.

61
Q

What should you do if the IME report does not address the questions in your cover letter?

A

Contact MCO Or IME provider and ask for and addendum

Contact SAIF the IME liaison

62
Q

What two questions to you ask yourself every time you review a claim?

A
  1. What do I need to do to bring this claim to resolution?

2. Are my reserves adequate?

63
Q

What elements are needed to stop or prorate time loss benefits when a worker has been terminated?

A
  • Employer has a written return to work policy
  • AP has approved the mod job description
  • A memo is on file with BJO info
64
Q

When can a worker refuse a modified work without facing a reduction or termination of time loss?

A
  • The IW is not physically capable of making the commute
  • Worksite is more than 50 miles away from the location of the injury
  • Mod work is not with the EAI
  • Mod work is not at a worksite belonging to the EAI
  • The shifts are different from what the IW typically workers?
65
Q

What is the purpose of the EAIP?

A

To encourage early return to work of the IW by offering financial incentives to the employers.

66
Q

What is the goal of vocational services?

A

Is to return the worker to a suitable work at a wage as close to 100% of the adjusted weekly wage as possible.

67
Q

What are some examples of optional services

A

GED classes
ESL classes
Career exploration or job development

68
Q

When to consider using option services?

A

IW lacks a GED or English language skills
Permanent limitations
IW is eligible for voc services

69
Q

What is the definition of likely eligible for voc services?

A

IW is unable to return to regular work or other suitable work with EAI, IW is unable to perform all of the duties of the regular work, and it is reasonable that these barriers are due to the accepted condition.

70
Q

What is the purpose of the Preferred Worker Program

A

It encourages reemployment of the workers whos injuries result in a disability which may be an obstacle for employment. It provides assistance to the employers who hire these IW.

71
Q

How many days does an employer have to request premium exemption from the PWP?

A

90 days from the date of employment.

72
Q

When would vocational services end?

A
  • The worker has been employed for greater than 60 days
  • Max voc services allowed
  • Claims is settled by CDA
  • Worker fails to cooperator with the voc process

Claims Exams (5 decks)

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