insurance claims processing review chapter 11
In which era did workers' compensation get its start?
1800s
Which of the following employers are not required to provide workers' compensation insurance to their employees?
All of the above.
Name the two distinct roles of the attending physician in workers' compensation claims.
Diagnose and treat work-related injuries and illnessesProvide claims administrator's opinions in response to specific medical and legal questions about work-related injuries or illnesses.
List the steps for filing a workers' compensation claim.
Employee notifies a supervisor of the incident immediately and provides the names of any witnesses.Employee completes a detailed accident report on a form furnished by the employer.Employer reports the incident to the company's workers' compensation carrier.Employee is sent to a medical facility for treatment or diagnosis. (In emergencies, this should be the first step.)Attending physician completes statement and distributes copies.Follow-up progress reports are submitted until the employee returns to work, after which a final report is filed. 0List the steps for filing a workers' compensation claim.
Certain classifications of businesses are not required to provide workers' compensation for their employees. List at least four.
Employers with a minimum number of full-time employees (fewer than three, and up to five, depending on the state)Executive officersIndividuals who are business partners (coverage is optional)Sole proprietors (most states allow optional coverage)"Casual" employees (A casual employee is one who is not entitled to paid holiday or sick leave, has no expectation of ongoing employment, and for whom each engagement with their employer constitutes a separate contract of employment. They often receive a higher rate of pay to compensate for a lack of job security and benefits.) 0Certain classifications of businesses are not required to provide workers' compensation for their employees. List at least four.
All business organizations are required to purchase workers' compensation.
False
Because of the extensive information and forms required for workers' compensation claims, it is almost impossible for fraud to occur.
False
Federal rules and regulations do not allow individual states to use claim forms other than the CMS-1500 to report workers' compensation claims.
False
If the individual sustains a job-related injury, benefits often begin immediately.
False
Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) are identical programs with the same requirements for enrollment.
False
The CMS-1500 is the standard form for billing disability claims.
False
The Federal Employment Compensation Act (FECA) provides workers' compensation for federal military employees.
False
The health insurance professional has no tangible responsibilities in facilitating disability claims.
False
Vocational rehabilitation is not available for employees who cannot return to their job because of a workers' compensation injury.
False
Which of the following is not one of the responsibilities of the health insurance professional?
Filling out the necessary forms for the patient
Workers' compensation benefits are not paid for certain work-related incidents when injury occurs as a result of certain irresponsible actions by the employee. Name four of these.
HorseplayDrunken stumblingIllegal drugs are involvedSelf-inflicted injuriesInjuries incurred while a worker is off the job, committing a crime, or violating company policy 0Workers' compensation benefits are not paid for certain work-related incidents when injury occurs as a result of certain irresponsible actions by the employee. Name four of these.
Which act provides workers' compensation to employees of private maritime employers?
Longshore and Harbor Workers' Compensation Act
Name the major benefit components to workers' compensation.
Medical expense pays the expenses involved for hospitalization, doctors' visits, and any necessary medical treatment.Disability pay can be either temporary or permanent if it is determined that the worker will never fully recover.Vocational rehabilitation may be necessary if the injury/illness results in the worker being unable to perform the usual duties of his or her occupation; retraining may be necessary in order for the worker to enter into a new trade or business. Physical therapy also may be necessary.Death benefits are paid to surviving dependents. 0Name the major benefit components to workers' compensation.
Workers' compensation insurance is no-fault insurance. Explain what this means.
No-fault insurance means benefits are paid to the injured (or ill) worker regardless of who is to blame for the accident or injury, barring specific exceptions mentioned in the textbook.
List at least four of the health insurance professional's responsibilities for facilitating disability claims processing.
Obtaining the patient's authorization to release informationAcquiring the necessary information and forms for claims processingEnsuring that the attending physician reports are complete and signedPhotocopying all forms and correspondence for the patient's health recordMaintaining a well-documented health recordAnswering the patient's questions 0List at least four of the health insurance professional's responsibilities for facilitating disability claims processing.
List and explain the two major classifications of disability coverage.
Short-term disability provides an income for the early part of a disability, typically 2 weeks up to 2 years.Long-term disability helps replace income for a longer period of time, up to 5 years or until the disabled person turns 65 years of age.
List at least six of the nine federal disability programs.
Social Security Disability Insurance (SSDI)Supplemental Security Income (SSI)MedicareMedicaidWorkers' compensationBlack lungVA Disability Compensation ProgramVA Pension ProgramVA Health Services Program 0List at least six of the nine federal disability programs.
Name the five specific items the attending physician's statement must typically include when a disability claim is filed.
The diagnosisThe first day the individual was unable to workWhether or not the illness/injury was work relatedNature of the treatment or suggested treatmentRestrictions and/or limitations 0Name the five specific items the attending physician's statement must typically include when a disability claim is filed.
What is the first step an employee should take for a first report of a nonemergency on-the-job injury?
The employee should notify a supervisor of the accident.
Which program was created to help individuals who receive SSDI or SSI benefits find and keep employment by offering them more options for services and supports?
Ticket to Work
Balance billing is not allowed on workers' compensation claims.
True
Disability income insurance replaces a portion of earned income when an individual is unable to do his or her work resulting from nonemployment-related injuries.
True
Each state has established rules under which an employee is required to file a claim within a certain time limit.
True
HIPAA mandates that if an employer provides insurance to its employees and their dependents, all employees and dependents must be covered regardless of medical condition.
True
HIPAA permits covered entities to disclose PHI to workers' compensation insurers and/or employers without the individual's written authorization.
True
Most short-term disability policies have a maximum benefit amount that is paid each month.
True
The purpose of disability income insurance is to replace a portion of salary or wages lost due to injury or illness that is not work related.
True
There are two major types of disability coverage, short-term and long-term.
True
There is no wage base limit for the Medicare Part A (hospital insurance) payroll tax.
True
Workers' compensation is considered no-fault, and benefits are paid regardless of who is to blame for the injury.
True
Any physical or mental impairments resulting from a work-related incident are normally determined on the basis of the
attending physician assessment.
A maximum amount paid per month for short-term disability policies is called a _____ cap.
benefit
Income from employment (wages) is considered
earned income.
Some commonly used factors federal programs look at in assessing disability include all of the following, except
earned income.
A detailed and comprehensive questionnaire that establishes monetary need is a/an
financial means test.
There are no work requirements for SSI, but the individual must establish
financial need.
All of the following are benefits of the workers' compensation program, except
food and housing expenses.
Companies pay premiums for workers' compensation insurance; in return, their employees agree to
give up the right to sue employers for on-the-job injuries.
The time limit for filing a workers' compensation claim is established by
individual state statutes.
Workers' compensation is considered a/an
legally mandated right.
As an alternative to traditional workers' compensation coverage, some employers choose a/an __________________ to provide medical care to injured employees.
managed care system
The standard form for billing disability claims is
nonexistent
The Federal Employment Compensation Act (FECA) provides workers' compensation for _____ employees.
nonmilitary federal
An individual responsible for investigating and resolving workers' complaints against the employer is called a/an
ombudsman
The condition in which the employee has reached a state of maximal medical improvement is called
permanent and stationary.
