BREAKDOWN AND EXPLANATION OF PROCEDURES FOR MEDICAL ONLY, LOST TIME AND LITIGATED CLAIMS

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1 BREAKDOWN AND EXPLANATION OF PROCEDURES FOR MEDICAL ONLY, LOST TIME AND LITIGATED CLAIMS The procedures governing handling the payment of workers' compensation claims are found within the Board Rules promulgated pursuant to the authority granted by the legislature in the Workers' Compensation Act, the Official Code of Georgia Annotated Title 34 Chapter 9. Generally, the statutory authority for each Board Rule corresponds with the Board Rule number. For example, payment of workers' compensation benefit is set out within the statute at O.C.G.A , while the procedure for that payment is found within Board Rule 221. Similarly, the employer's pecuniary responsibility for medical treatment is governed by O.C.G.A and Board Rule 203. The legislature also authorized the State Board of Workers' Compensation to publish and utilize certain forms in order to carry out the purposes of the Act. Those forms are authorized at O.C.G.A and the proper utilization of those forms is explained in Board Rule 61. Effective and timely referral to both the statute and the Board Rule will assist you in gaining and maintaining the degree of control allowed by the Act. Effective claims handling by utilization of Board Rules will prevent the imposition of penalties for late or incorrect payment. MEDICAL ONLY CLAIM 1. WC-1(First Report of Injury). Correctly complete the First Report of Injury, Form WC-1 and complete Subsection (A). Assuming that the employee is not disabled as a result of the injury, the original copy of the WC-1 will be maintained in the adjuster's file. This form must be stamped on the front side of the WC-1 in large red letters with the word "MEDICAL ONLY" and should be completed within 21 days of notice of the injury. If the employee subsequently begins losing time, the" original WC-1 should be forwarded to the State Board of Workers' Compensation. 2. WC-6 (Wage Statement). It is not necessary to complete on medical only cases unless specifically requested by claimant or claimant's counsel. If the requested, provide within 30 days but do not file with the State Board. NOTE: IT IS A GOOD IDEA TO OBTAIN A WAGE STATEMENT ON EVERY CLAIM IN CASE THE EMPLOYEE LATER BEGINS LOSING TIME. 3. Payment of Medical. Pay all bills pursuant to the fee schedule within 30 days of receipt of bills and supporting medical records. Medical providers are not required to request precertification. If requested in writing, however, payor must either authorize the requested procedure or controvert by WC-3 within thirty (30) days. Failure to do so will result in the requested procedure being deemed authorized.

2 4. WC-26 (Yearly Reporting of Medical Only Cases). File before January 31st of each calendar year. 5. WC-102 (Request for Document to Parties). Request for documentation may be filed without the need for pending administrative hearing. All information must be furnished to the requesting party within 30 days of request. 6. WC-104 (Notice of Release to Return to Work with Restriction). Any time an employee is released to return to work at light duty by the authorized treating physician, Employer/Insurer should complete a WC-104, attaching light duty release by physician and serve on employee, counsel (if applicable) and file with the State Board of Workers' Compensation. 7. WC-240 (Notice of Offer of Light Duty Work). While the statute is not clear on this point, the State Board seems to be leaning toward requiring approval of any light duty job by physician with notice being given to the Employee. LOST TIME CLAIM 1. WC-1. Complete and file WC-1 within 21 days from notice. Always complete Subsection A with as complete information as possible. If income benefits are being paid, complete Subsection B showing average weekly wage (AWW) and compensation rate (TTD or TPD). If paying less than the maximum compensation rate (TTD or TPD) either complete wage statement on the reverse side of the WC-1 or complete a separate WC-6 form and file with the State Board of Workers' Compensation. Complete Subsection C only when controverting the right to income benefits or the entire claim. If controverting only medical treatment, use the WC-3 form. Also use WC-3 when First Report of Injury has been previously filed. 2. Rule 221 (Payment of Benefits) No immediate payment of TTD for the first 7 days of disability. First payment of disability for days 8 through 14 should be paid on day 8 with weekly payments thereafter. Payments for disability days 1 through 7 need not be paid until the claimant is disabled for 21 consecutive days. On the 21st day of disability, pay disability days 1 through 7 and disability days 21 through WC-2 (Notice of Payment/Commencement of Benefits) Use of payment/commencement of benefits if WC-1 has been previously filed. For suspension of benefits, complete Subsection B of WC-2 as follows: a. Actual return to work - suspend benefits immediately; b. Release without restrictions by authorized physician - payment of compensation to date with payment of an additional 10 day notice. Attach normal

3 duty release to the WC-2 and file with the State Board of Workers' Compensation. Serve a copy of WC-2 on claimant. c. Return to work at less than pre-injury wage - pay temporary partial disability (TPD) per calculations in O.C.G.A Medical Benefits - treated similarly to medical payments for medical only claims. 5. WC-4 (Case Progress Report). Should be filed: (a) when the claimant actually returns to work; (b) not later than 90th day of disability; (c) within 30 days of last payment of benefits to close out case; (d) to reopen a case; and (e) upon order from the State Board. 6. PPD Benefits - within 30 days of claimant losing entitlement to TTD and TPD, request rating from authorized treating physician. Rating must be made in compliance with AMA Guides Permanent Impairment, 4th Edition. If necessary, schedule return appointment for claimant to be evaluated and rated. NOTE: The employer is presumed to have notice of the rating 10 days after issuance by the authorized treating physician. 7. WC-102 (Request for Document to Parties). Request for documentation may be filed without the need for pending administrative hearing. All information must be furnished to the requesting party within 30 days of request. 8. Catastrophic Claim. For catastrophic claim (1) spinal cord injury involving paralysis (2) amputation of arm, hand, foot or leg; (3) severe head injury; (4) second or third degree burn over 25% of the body as a whole or greater than 5% to the face or hand; or (5) total industrial blindness) file WC-1 with the State Board within 48 hours. Also within 48 hours, file WCR-1 designating catastrophic rehabilitation supplier. 9. Light Duty Return to Work. For claims after July 1, 1994, file Board Form WC- 240 with the State Board serving a copy of the claimant and, if applicable, claimant's attorney. The WC-240 shall include the light duty job offered, a description of the light duty job approved by the treating physician within the last 60 days and directing the claimant when to return to work and to whom the claimant should report. The employer should send a copy of the light duty job description to the claimant or claimant's attorney at the time that it is submitted to the doctor for approval. Failure of the claimant to report to work authorizes the employer to unilaterally suspend income benefits. The claimant shall be entitled to a 15 day grace period during which he or she can attempt the job. If the claimant returns to work at the assigned date but is unable to complete the job for 15 days, income benefits must be immediately recommenced. Failure to immediately reinstate benefits results in an automatic waiver of defense that the

4 job was suitable. If the employer believes the claimant is unreasonably refusing to work or is insincere in the job effort expended to return to work, a hearing must be requested. Also, use WC-104 for all claims occurring after July 1, 1992 irrespective of whether the employee actually returns to light duty work or a light duty job has been offered pursuant to WC-240. LITIGATED CLAIMS The litigated claims should be handled consistently with the procedures of the medical only and lost time claims. The primary difference is, of course, that a represented claimant in a litigated claim may very well be off limits to first person contact. This issue may vary, however, depending on the comfort level of the claimant's attorney. In addition, any forms which were previously copied to the claimant should now be copied to the claimant and his or her attorney. 1. Notice of Hearing. Board Rule 102(i)(3) mandates that a party notify the State Board of its designated representative within 21 days of the date the hearing notice is issued. Failure to do so can result in the imposition of a $ fine. In all practicality, this is only applied to the employer and was designed by the Board to discourage the employer from, at the last minute, retaining counsel and forcing a continuance of a long scheduled hearing. Notification to the Board needs to be made by designated counsel on a form WC-102(i) (Notice of Representation) filed with the Board no later than 21 days after the issuance of a hearing notice. 2. Change of Physician. If the parties are not able to agree upon a designated physician for alternative/additional treatment, the requesting party must file a request with the State Board, serving a copy on the opposing party on Board Form WC-200(b) stating the name of the current treating physician, the name of the physician to whom the change is requested and the reason for the requested change. If the opposing party does not wish to agree to the change of physician, an objection must be filed within 15 days of the date of mailing of the Motion to Change Physicians. The objection shall be filed likewise on Board Form WC- 200(b) and shall contain the reason for the objection. (A list of possible objections is contained with Board Rule 200(b)(2). A change of physicians by consent must be memorialized on Board Form 200(a). 2. Request for Advance. The claimant may request an advance on future benefits (generally PPD benefits) by filing Board Form WC-25. Unless the advance is agreed upon, the employer must file an objection to the request for advance within 15 days. 3. Miscellaneous Objections. Any party may file a motion with the State Board for various purposes, such as an Interlocutory Order to recommence benefits pending a hearing, suspend benefits based upon (a) refusal to cooperate with

5 medical treatment; (b) refusal to return to suitable employment. The responding party, unless agreeing to the Motion, must file an objection with the State Board within 15 days of the date on the Motion. Disclaimer: The reader is cautioned to use extreme care in applying the legal principles discussed in these articles. Competent legal advice should always be obtained to properly apply the relevant law to the specific facts of any case.