What s new in 2017 Workers Compensation Law. How to report paid benefits timely

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2 What s new in 2017 Workers Compensation Law Why pay benefits timely How to pay benefits timely How to report paid benefits timely How to do everything else 2

3 Terms appear intentionally ambiguous or remain undisclosed. Judicial Review simultaneous copy of petition. Proposed agreed judgment. 3

4 DWC shall investigate fraud. DWC subpoena for investigation (documents or testimony). DWC provides technical & litigation assistance to appropriate action. Increases threshold value of benefits from $1500 to $2500 for a Class A misdemeanor. 4

5 Designated Doctor & Agent (scheduler, billing, organizing medical records) not subject to disclosure. 5

6 Employer Representatives who terminate WCI with no certified mail. Insurance Company who cancel/non-renew -> electronic means. DWC notification. 6

7 OIEC recommendation. Taking 15 months to fill an Ombudsman vacancy. 7

8 Applies only to spouse who remarries after the effective date of accident. 8

9 Does not seem to change anything. Sleep Deprivation. 9

10 Limits damages to $100K for each person aggrieved & $300K. 10

11 Public Counsel shall designate a liaison. Must be an Ombudsman. Public entities must notify first responders of liaison. 11

12 Tackles DWC penalties for only EDI issues. Negative impact on delivery of benefits to IE. DWC must tell IC the (1) Statue/Rule (2) conduct, (3) factors considered. 12

13 Hearing Officers to Administrative Law Judges. 13

14 Posting a bond may pose a financial barrier to court access of any JR. 14

15 501 covers non-governmental entities & local governmental entities. AWW any employment not to exceed SAAW 100%. Provides WC coverage to non-state EE task force members. 15

16 For self insured who withdraws from selfinsurance can purchase WCI. Must provide an adequate plan approved by DWC. 16

17 Include minimum balance for $ 1 million to $2 million. Include cap from $2 million to 3% of the combined value of one time security deposit (replaces $ cap to a risk-sensitive cap). BOD recommends trust fund balance to DWC adopt a year to year schedule of assessments. 17

18 Treating Doctor may delegate a licensed Physician Assistant to complete DWC-73s. 18

19 Political subdivisions waive but State does not. 19

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22 Right thing to do Compliance PBO 22

23 Ongoing TIBs Ongoing IIBs or no IIBs Accuracy of LIBs Accuracy of DBs 23

24 Timely payment of IP (40%) Timely reporting of IP via EDI Timely payment of medical 20% initial 20% recon Timely reporting thru M-EDI 24

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26 Written Notice Name DOI Employer Facts asserting compensability Oral Notice 26

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34 Advantages Do not owe accrued benefits Disadvantages Limited to defenses on denial Limited time to conduct investigation 34

35 Advantages Full 60 days to conduct thorough investigation Disadvantages Must pay all accrued income & medical benefits 35

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37 PLN-1 Make sure PLN-1 is timely filed 15 days, OR 60 days Send to: Claimant Attorney DWC thru boardrep, AND EDI 37

38 Avoid: Acronyms Legal citations or legalese questions the injury First Paragraph ALL legal defenses Second Paragraph Claim-specific facts to support the legal defenses 38

39 Notice of Denial of Compensability/Liability and Refusal to Pay Benefits We, [Name of carrier], reviewed your workers compensation claim. Based on the facts we have about your claim, we are not going to pay income or medical benefits. We denied your claim because: [Provide full and complete statement explaining the action taken] 39

40 DWC-3 wage statement DWC-3ME multiple employment DWC-6 supplemental report PLN-2 IP PLN-6 FS PLN-8 CA PLN-10 RB 40

41 Send Check PLN-2 (or PLN-5) Claimant Attorney NOT boardrep EDI EDI Make sure the date your report check mailed is the date you mailed the check 41

42 Date paid v. date paid reported Intermittent disability DWC believes it is IC s responsibility to know if and when claimant is working Accuracy Deadlines 42

43 More than one IP CB not appropriate for TIBS to IIBS PLN-1-10 have a corresponding EDI MTC Full Salary not reported CO (non-critical DWC identified errors) v 02 (carrier determined errors) SROI only if benefits are initiated Sequencing 43

44 Late Initiation of Benefits Traditional Loss Time Calculation Split Loss Time Calculation Delayed Loss Time Calculation 44

45 Sun Mon Tue Wed Thur Fri Sat 30 1 st Notice 1 1 st Day of LT th Day of LT Pay or Dispute Pay Week Pay Week

46 Sun Mon Tue Wed Thur Fri Sat 30 1 st Notice 1 1 st Day of LT 2 2 nd Day of LT 3 RTW 4 RTW 5 RTW 6 3 rd Day of LT 7 4 th Day of LT 8 5 th Day of LT 9 6 th Day of LT 10 7 th Day of LT 11 8 th Day of LT Disput e Today Pay First 2 Weeks Pay Week Pay Week

47 Sun Mon Tue Wed Thur Fri Sat 30 1 st Notice 1 RTW 2 RTW 3 RTW 4 RTW 5 RTW 6 Day Off 7 Day Off 8 RTW 9 1 st Disab Dispute Today 16 8 th Disab Pay First 2 Weeks

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49 1/2 DOI 1/3 LT begins 1/4 IC notified 1/5 EDI: FROI-00 1/10 8 th day of disability 1/16 IC determines claim is compensable 1/17 IP: date check left IC possession 49

50 Sun Mon Tue Wed Thur Fri Sat DOI 1 st Day Of LT IC Notified EDI: FROI th Day IC Accepts 17 EDI: Check Pay Week Pay Week 4 50

51 1/24 ER stops paying health insurance 51

52 Sun Mon Tue Wed Thur Fri Sat DOI 1 st Day Of LT IC Notified EDI: FROI th Day IC Accepts 17 EDI: Check ER Stops Ins

53 2/5 DWC-73 RTW FD 2/6 TIBS suspended 2/7 RTW 2/9 Payment issued 2/12 Check mailed 2/16 DWC-73 reduced hours/money 53

54 Sun Mon Tue Wed Thur Fri Sat DWC-73 RTW FD TIBS Stop RTW Check issued EDI Limited to 6 hours

55 2/21 DWC-73: off work 2/28 TIBS issued 55

56 Sun Mon Tue Wed Thur Fri Sat DWC- 73 TIBS Stop RTW Check issued EDI Limited to 6 hours DWC- 73 OFF EDI

57 3/6 MMI with a 1% IR 3/15 TD exam 3/28 IIBs ended/ suspended 57

58 Sun Mon Tue Wed Thur Fri Sat MMI 7 IIBs begin DWC- 69 MMI IIBS end 58

59 1/2 DOI 1/3 LT begins 1/4 IC notified 1/5 EDI: FROI-00 1/10 8 th day of disability 1/16 IC determines claim is not compensable 59

60 Sun Mon Tue Wed Thur Fri Sat DOI 1 st Day Of LT IC Notified EDI: FROI th Day IC denies PLN-1 deadline

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64 RULE If the injured employee is still employed by the employer at the time of injury, the employer is responsible for informing the carrier of changes in the employee's weekly earnings after an injury REAL LIFE IC is responsible for calling the injured worker every week 64

65 RULE If the employee is no longer employed by the employer, the employee is responsible to provide information to the insurance carrier about the existence or amount of any earnings, or any offers of employment. REAL LIFE IC is responsible for calling the injured worker every week 65

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67 BFOE is difficult Skilled plaintiff attorneys can overcome BUT No BFOE does not mean disability if the IW did not avail himself of reasonably available employment IW does not have to search for work But can t avoid it either 67

68 We hope that you are recovering quickly from your injury at work. You are a valued employee. As such we, want you back to work as quickly as medically possible so you do not lose any income. In order to assist our workers who sustained injuries on the job, we have a policy to return you back to work consistent with the restrictions listed by the doctor on the attached DWC

69 It is against company policy for any other employee to ask you to work outside the restrictions outlined by your doctor. It is also against company policy for you to work outside of these restrictions whether or not you are requested to do so or not by another employee. If anyone requests that you work outside of these restrictions, please report this activity to your supervisor or the undersigned immediately. 69

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71 15 or 60 day pay or dispute 15 Day Deadline File dispute (PLN-1) Don t pay benefits Limited to defenses filed 60 Day Deadline Pay all accrued benefits (including medical) More time to investigate 71

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73 Accident did not arise out of and in course and scope of employment Origination Prong: Did not arise out of the work, business, trade, or profession of the employer Furtherance Prong: Not furthering the affairs of the employer 73

74 Coming and going rule Employer provide travel? Access doctrine exception Special Mission Doctrine Deviation Dual Purpose Rule 74

75 No injury Borrowed servant or co-employers Personal comfort and convenience doctrine Injury due to participation in off duty recreational, social or athletic activity that was not required by employer. Intoxication (Mixed or shifting burden) 75

76 Horseplay Personal Animosity Act of God 76

77 Notification of Maximum Medical Improvement and Impairment Rating (DWC FORM PLN-3), Rule 124.2(e)(1),(4), and (5), and (f); (MTC: IP, CB,RB) This is a letter for the Notification of MMI/IR and will serve as a notice of payment or non-payment of 030 (IIBs). This letter may be used if the payment of 030 (IIBs) benefits is the first payment of income benefits (IP), the change from TIBs to IIBs (CB), or when IIBs are being reinstated after the payment of TIBs has been suspended (RB). 77

78 We, [Name of carrier], are letting you know that we will not pay you workers compensation impairment income benefits. The reason for this is because the report (copy attached) from Dr. [First and last name of doctor] shows that: You have reached maximum medical improvement, which is when either: (1) no further healing or recovery from your injury can be expected, or (2) you were paid temporary income benefits for as long as the law allows. The doctor checked how your work-related injury affected your whole body. The doctor either: Gave you an impairment rating of 0%. This rating shows that, although you have or had an injury, there is no permanent damage to your body as a whole. or Did not give you an impairment rating and found that you have no permanent damage to your body as a whole. 78

79 Dr. [First and last name of doctor] sent your report (copy attached) and it shows: You have reached maximum medical improvement, which is when either: (1) no further healing or recovery from your injury can be expected, or (2) you were paid temporary income benefits for as long as the law allows. The doctor gave you an impairment rating of [Rating number] %. This rating shows to what percent the work-related injury affects your body as a whole. 79

80 Your income benefits are changing from temporary income benefits to impairment income benefits. This change is happening because: (1) you were paid temporary income benefits for as long as the law allows (maximum medical improvement), and (2) you did not get an impairment rating from a doctor. With the facts we have, we believe your workrelated injury has a rating of [Rating number] %. This rating shows to what percent we believe the injury affects your body as a whole. 80

81 DWC certification 4 Doctors TD Or, TD s referral doctor but not both DD Post DD RME 81

82 Paid as of day after the date of Maximum Medical Improvement Party has 90 days to dispute MMI/IR or certification will be final, with exceptions A DWC-45 requesting a BRC or a request for designated doctor appointment must be filed for a valid dispute 82

83 Within 5 days of receiving the DWC-69 PLN-3 by verifiable means 83

84 Some Random Deadlines 84

85 15 v days to pay pursuant to DD report 90 day finality of MMI/IR 45 day medical bill 85

86 Interlocutory Order must be paid within 5 days (states on the order) Benefit Dispute Agreements must be paid within 5 days of approval (states on the agreement) 86

87 Decision and Order from Contested Case Hearing (Rule ) If no appeal, payment due within 36 days of the date received from the Division (order final on day 20 and 16 days to comply) If appealed, payment due by 5 th day after filing a Request for Review Interest must be paid on all accrued, but unpaid benefits (both income and medical) 87

88 Interest on accrued but unpaid benefits shall be paid, without order of the commissioner, at the time the accrued benefits are paid. Section

89 Rulings of Appeals Panel (Rule 143.5) Final on the 41 st day after the date the decision is filed (generally filed date noted on the top of decision letter) Payment due within 20 days of becoming final, or by day 61 89

90 Attorney fees- Claimant- Begin payment at next income check Carrier- to be paid within 20 days of receipt to avoid a violation 90

91 THANKS 91