Workers' Compensation Program

Transcription

1 Pinellas County Schools Workers' Compensation Program Manager Information Guide Risk Management & Insurance Administration Building (727) Fax (727) Fax (727) (alternative) Updated: June 1, 2007

2 Introduction What do managers and supervisors need to know about workers compensation? General Workers Compensation Page Information 3 Claim Reporting Procedures 6 Payroll Procedures 10 Leave of Absence Policy and Procedures 14 Additional Employee Questions 17 Advice From the Experts 19 2

3 General Workers Compensation Information Policy: Pinellas Co. Schools provides Workers Compensation benefits for its employees under Florida Workers Compensation Law, Chapter 440. Injuries and illnesses arising out of or in the course of employment will be covered. All workers compensation claims must go through a managed care network. 3

4 Basic Facts About Workers Compensation 1. Every employee in Pinellas County Schools is covered under Workers Compensation, including registered volunteers. 2. Workers Compensation coverage will pay for the most reasonable and necessary medical care if an employee has an illness or injury arising out of or in the course of his/her employment. Medical care includes: visits to approved health care providers surgery and hospital care prescription drugs medical supplies 3. Pinellas County Schools has the right to choose the medical providers. 4. Workers Compensation will replace part of an employee s wages if a workers comp doctor takes him out of work (66 2/3% of average weekly wage, up to a yearly state maximum.) 5. Routine doctor follow up visits, outpatient testing and treatment or therapy, should be scheduled outside of the normal workday, since these absences are not paid under workers compensation. In some instances, specialists visits may be covered if appointment hours are not available outside the employee s schedule. 6. Under Pinellas County Schools board policy, notice of Injury reports must be reported within 24 hours. 7. Under Florida Law, employees must advise the employer of an injury within 30 days after the date of the injury. Claims reported after the 30 days will not be covered. However, due to exceptions and extenuating circumstances outlined in the regulations, ALL cases should be reported (even if it is after the 30 days). 4

5 Who s Who?? RISK MANAGEMENT -Coordinates payroll -Assists Employee PHYSICIAN Managed care coordinator -MCC -Primary physician within workers compensation network JOHNS EASTERN Third Party Administrator -pays and manages workers compensation claims 5 JOHNS EASTERN - provides nurses to assist with medical aspect of claim

6 Claim Reporting Generally the manager or supervisor is the first on the scene of an injury. Create a supportive environment for injured workers, even if there are suspicious circumstances. Treat every injury as legitimate. The first 24 hours after the injury are critical and can mean the difference between a costly, prolonged claims process and a smooth return to work. 1. Respond to injured employee-- Stop and assist the employee. Make immediate contact with the injured worker to get the facts. Reconfirm that Pinellas County Schools has a process in place to take care of injuries. 2. Make sure employee receives medical attention-- Each supervisor should know: who the medical caregiver is going to be where the closest providers are located which ambulance or other transport service will be used in emergency situations 3. Complete Injury Report Each supervisor should know: How to complete the First Report of Injury Form (see Telephonic Reporting) 4. Investigate the accident Following an accident and after a First Report of Injury is completed, there should be some additional investigation beyond the first report to identify the underlying causes of the accident. Once you figure out what caused the accident, corrective action can be taken to prevent a recurrence of that type of accident. Employee Injury Investigation forms are available through Risk Management (PCS Form 3-870). 6

7 Employee is injured Contact supervisor Investigate Accident Complete PCS Y Is emergency medical care required? N Option 1 Option 2 Secure emergency medical care for employee Get Claim Worksheet Access & Print B01 Alt Screen off Terms Employee & Employer complete claim form TPA distributes DWC1 to: Employee Department/School Johns Eastern Company Risk Management Y Medical Care Needed? N Arrange for Employee to visit network provider. File as an Incident only (No medical treatment) Record Injury on SAF 200 Log 7

8 Workers Compensation Claim Worksheet Account Name : Pinellas County Schools Location ID * ( *Cost Center of Employee) Name, Title & Phone # of person calling in report Date of Injury EMPLOYEE INFORMATION Name Social Security # Sex Date of Birth Marital Status # of Dep Address City State_FL_Zip Date of Hire Occupation Weekly Salary (Biweekly pay divided by 2) No. of Hours per Day No. of Days Per week INJURY INFORMATION Time of Injury Date employer notified Employee paid in full for day of injury (Yes/No) Was injury on employer s premises (Yes/No) Doing Regular job? (Y/N) Last work date (if lost time) Has employee returned to work? (Y/N) When Address where injury occurred If employee received treatment, Name and Address of Doctor or Hospital Description of Accident & Body Part Affected Supervisor s Name Employee Signature (if available) Confirmation# (provided by Telereporting Agent) Please use to report this incident.

9 Workers Compensation Payroll Procedures Reminder: If an employee is absent due to a job-related accident or illness, the time should be reported on the normal certificate of absence report form. 10

10 1. A certificate of absence must be completed to report any absences. When the initial injury and lost time occurs, under the explanation of Codes, indicate: S= Sick Leave with Pay X Illness/Injury in the line of duty. 2. Fax the certificate of absence to Risk Management or The copy faxed to Risk Management does not require an employee signature. If delayed, this may cause administrative errors for the employee and payroll specialist. 4. Do not code W or WC on the certificate or in TERMS. These codes are reserved for Risk Management, and used only after a determination has been made on lost time. 5. After the employee has been out of work beyond the ten days paid as worked (in line of duty pay*), a leave of absence form should be generated. *In line of duty benefits will only be paid out if the workers compensation doctor s note indicates the employee must be off work - or if the employee s light duty restrictions could not be accommodated at the work site. 6. After the 10 days have been paid out under school board policy, Risk Management will adjust the employee s sick or vacation time so that an employee will receive a paycheck (JECO may pay 66 2/3% of your average weekly wage, up to a state max), and Risk Management adjusts the difference up to 100%. You must continue to submit the certificate of absences by fax to Risk Management until the employee returns to work. 11

11 Insert example of Certificate of Absence 12

12 Leave of Absence Policy & Procedures Policy: Leave with pay for illnesses or accident incurred in performance of duty shall be provided by Florida law and according to board policy. 13

13 Leave of Absence Policy & Procedures Leaves are administered through Personnel. Medical Leaves for the employee may fall under a) family medical leave act or b) the school board provisions of a Regular Medical Leave. Employees that have an illness or injury under workers compensation must be placed on a formal leave of absence if their absence exceeds 10 working days. It is the supervisor s responsibility (school or department) to complete the leave paperwork. An employee signature is preferred but not required. 14

14 Common Questions & Answers 1. What is Family Medical leave? An employee has a right under the Pinellas County Schools Leave of Absence policy (and Federal regulations) for up to 12 weeks of unpaid or paid (if the employee has sick or vacation time available) leave --in a floating 12 month period for the following reasons: A serious health condition of the employee* To care for an employee s spouse, child, or parent with a serious health condition Birth of a child Placement of a child with the employee for adoption or foster care *In some circumstances, a leave for a serious health condition may be intermittent. 2. Who is entitled to Family Medical Leave? Employees are eligible for family medical leave if they have worked for PCS for at least 12 months prior to the request for the leave, and have worked 1250 hours or more during that period. 3. Is the employee s job protected while on family medical leave status? If an employee is eligible for a family medical leave, Pinellas County Schools must restore him to the position that he held prior to his leave or an equivalent position. An equivalent position is one with equivalent pay, benefits, and other terms and conditions of employment. If an employee s leave continues beyond the 12 weeks of authorized family medical leave, his additional leave is considered a Regular Leave. An employee s job is not always protected under a Regular Leave.**--However, a manager must consider the American Disabilities Act (ADA) and reasonable accommodations. **A manager should seek consultation through Personnel or the Equal Opportunity/Employee Relations office prior to filling an employee s job, when the employee is out on a medical leave.

15 4. How are an employee s insurance benefits affected when he is out on a medical leave of absence? If the employee is on a family medical leave or is on a paid leave (through sick or vacation hours), the employee is eligible to receive the board contribution towards insurance. If the employee is on a regular unpaid medical leave, the employee may continue his insurance, however he is responsible for the full cost of the insurance. When an employee is no longer receiving a paycheck--the Risk Management department bills the employee for insurance through billing coupons mailed to the home. The employee may qualify for a health insurance waiver, after exhausting family medical leave. This waiver allows the employee to continue his health insurance while the school district pays the full cost of insurance (employee and Board contribution). In order to qualify for this benefit the employee s doctor must complete a waiver application and state the employee is completely and totally disabled. * If the employee is not placed on a leave properly and in a timely manner, the employee s ability to continue insurance coverage is jeopardized and the cost of the insurance is increased dramatically. 16

16 Additional Employee Questions 1. If I am not happy with the medical treatment I am receiving, what can I do? An employee may file a complaint through an informal or formal grievance process by contacting the managed care company or the employee s adjuster. Through this process, an employee may seek a second medical opinion, a change of physicians, and an independent medical examination. 2. Must I be released full duty before I can return to work? No. Your doctor may release you for modified or light duty work before you reach maximum medical improvement. (MMI is a term used to describe the point in time when the treating physician believes the injured worker has recovered as much as he or she is going to.) Your supervisor will attempt to provide you a modified position within your restrictions on a temporary basis--not to exceed 90 days. If work is not available at your original work site the personnel department will work with you through the LAD s (Light Alternative Duty) program. This is a district wide program designed to offer a temporary (90 days or less) alternative work site within the district where you can function during the healing process. 3. What if my doctor says I cannot return to my original position? Once the authorized treating physician states in writing that you have permanent restrictions, you will be evaluated for your ability to return to your original position and perform the essential functions of the job with or without accommodations. If you cannot return to your original position because of permanent restrictions, then you will be placed in a comparable position based on availability. You must meet the minimum qualifications and perform the essential functions of the new job with or without accommodations. Placement will not result in a promotion. 17

17 If a comparable position is not immediately available, and you have not exhausted any eligible family medical leave, you will be placed on a leave. During this leave period, you, in conjunction with Personnel, should seek employment within your restrictions and qualifications. Benefits will be granted upon leave of absence provisions. If you have reached Maximum Medical Improvement, with permanent restrictions, but have already exhausted FMLA, you will be placed on Pending Placement. During this period, you, in conjunction with Personnel, should seek employment within your restrictions and qualifications. 4. Are workers compensation benefits taxable? No. 18

18 Advice from the experts... Promote safety before the accident occurs. After an accident occurs, report the incident and investigate the situation right away. Maintain contact with the injured employee. Know how the system works so that you can help the employee through the system efficiently and effectively. By knowing how to handle a workers compensation claim once an injury does occur, you can help your employees get the benefits they deserve, keep the insurance company and the employer from paying out benefits that are unwarranted, and avoid litigation with all its cost, both in time and money. 19