Workers Compensation. Workers Compensation

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1 Federal and State Administration Qualifications for coverage Classifications of cases Physician reimbursement Billing and claims processing 2 1

2 Federal and State Laws Employers required to provide workers compensation coverage for work-related illnesses or injuries Minimum standards must be met Employee must be non-negligent in performing assigned work-related duties 3 Federal Programs Energy Employees Occupational Illness Compensation Program Federal Black Lung Program Federal Employees Compensation Act (FECA) Longshore and Harbor Program 4 2

3 Federal Programs for Prevention Mine Safety and Health Administration (MSHA) Occupational Safety and Health Administration (OSHA) Material Safety Data Sheets (MSDS) information regarding chemical and hazardous substances 5 State Programs Board or Commission Weekly cash payments while employee is unable to work Healthcare cost reimbursements Variety of coverage models based on an employers needs but must meet the mandated coverage requirements 6 3

4 Eligibility Requirements Workers compensation coverage is available for workers who are injured or become ill while performing the services or tasks required by their employment. 7 Categories of Compensation Cases Medical treatment Temporary disability Permanent disability Vocational rehabilitation Survivor benefits 8 4

5 Employer benefits Better protection of HR and lower costs Employee benefits Managed Care and WC Greater healthcare coverage Better access to appropriate medical treatment = better outcomes Ease of coordination/resolution of grievances No out-of-pocket costs 9 First Report of Injury First step in the workers compensation process Completed by the physician/provider when the patient is first seen by the physician for evaluation of a work related illness or injury. Completed in quadruplicate (4 copies) State Board/Commission Employer-designated compensation payer Ill or injured party s employer Patient s work-related injury chart 10 5

6 Key Information Name and address of current employer Name of the or ill or injured s immediate supervisor Date and time of the accident or initial onset of the signs or symptoms of illness Site where injury occurred Patient s own description of the onset of the condition place, time, circumstances, etc. 11 Form Completion Physician is responsible for completing First Report of Injury form. Date of claimed injury must be accurate i.e. patient was handling substance on 7/12/XX and began having difficulty breathing and rash on 7/14/XX the date entered should be 7/12/XX Do not leave any section of the report blank be as specific as possible in all entries 12 6

7 Physician s Progress Notes Patient s name and case number must be documented in the note Treatment and progress patient is making Current work status Documented statement of further treatment needed Future prediction for work status or disability Copies of consultations, lab or X-ray reports substantiating condition 13 Copies and original documents personally signed by physician Patient not required to sign to release information to compensation payer or state board/commission Duplicate: Physician s Progress Notes 1 copy to compensation payer 1 copy to remain in patient s medical record 14 7

8 Key Billing Points Eligible: Employees of for-profit organizations, state and federal employees, coal minors and longshoreman and harbor workers Administered by federal or state plans State plans may include state funds, commercial payers, or employer s special capital funds 15 Forms required for billing Workers Comp First Report of Injury Narrative/progress notes CMS 1500 Claim form Filing Deadline Key Billing Points Determined by state law and varies from payer to payer 16 8

9 No deductible No copayment Key Billing Points Premiums are paid by the employer Fees are determined by state compensation board All providers must accept assignment balance billing not allowed. 17 The End 9