Chapter 14 Workers Compensation

Worker's compensation

Benefit program that requires an employer to pay or provide insurance for lost wages, medical expenses to employee injured on the job.

OSHA provides regulations specific to health care. Some of these are

Blood born pathogen standard, PPE Standard, Respiratory Protection Standard, TB Compliance Directive

Commercial Insurance Workman's Compensation

Commercial insurance that meets state guidelines on workman's comp coverage

Providers of workers compensation patient should

Create a separate file that deals with just the injury issues. In EHR, create separate notes file for these injury notes

Federal Employee's Comp Act (FECA) provides workman's compensation to

Federal and postal employees around the world. Ran by a vendor called ACS, to be compensated, provider must join program which also allows access to authorization, check bill payment, and see Remittance Vouchers (RV). Provider accepts payment and may not bill patient for worker's comp care balances

Can providers bill patient for workman's comp injury care?

No, a provider must accept payment from workman's Comp fund and may not bill patient

Federal Black Lung Program covers/pays for what?

Only those related to pneumoconiosis. (Other injury or illness not covered by this program) including providers visits, inpatient and outpatient charges, diagnostic tests, RX drugs, ambulance services, travel for care if less than 200 miles round trip. There are no deductible or copays.

Worker's compensation payers/state boards can review

Only treatment data and history related to the on the job injury. HIPAA rules do not apply for these claims

Energy Employee Occupational Illness Comp Program (EEOICP)

Provides lump sum compensation for health benefits for those DOE Nuclear weapons workers injured on job. Two parts Part B covers eligible employees and survivors up to $150,000 for radiation and beryllium related illnesses/death. Part E covers eligible employees and survivors up to $250,000 for exposure to toxic substances at a DOE facility, mine or mill.

Who pays workman's comp insurance premiums?

The employer pays. May not charge employee for cost

Workman's Compensation Claims completion for patients for care

1. Employee files claim with employers workers comp insurance 2. Date of injury/illness is established 3. Employee is assigned a claim number which ascots as their insurance ID number

Provider needs following info for workers comp claim submission

1. Patient name, DOB, SSN, ADDRESS and Phone 2. Employers name, address and phone 3. Workers compensation carriers address, phone and claim number 4. Injury info such as date, place, detailed explanation of how occurred 5. CMS 1500 completed, first Report of injury Form, and office encounter notes are all submitted together for payment to the Workers Compensation insurance payer

Four copies of the First Report of Injury Form are needed for

1. State workers compensation board 2. Employers designated compensation payer 3. Employer of ill/injured employee 4. For chart of patient

Federal Black Lung Program is run by

Division of Coal Mine Workers Compensation through the Dept of Labor

Self Insurance Workers Compensation plans

Employer must set aside state mandated % of capital fund funds to cover workman's compensation coverage of care, wages, etc

Federal workers are covered under one of the following workmen's compensation programs

Energy Employee Occupational Illness Comp Program (EEOICP), Federal Employee's Comp Act (FECA) Longshoremen and Harbor Workers Comp Program, or Federal Black Lung Program

To qualify for workman's compensation employee must be

Injured while working within scope of job description, injured while performing services required by employer, contract an illness that can be directly connected to employment. They are covered regardless of who is at fault.

Healthcare workers include

Medical staff, maintenance, housekeeping, food service, laundry, administrative staff

Federal Black Lung Program and Medicare. Who is primary when?

Medicare is secondary for covered conditions and primary for non covered conditions

Longshoremen and Harbor Workers Comp Program covers

Most waterfront workers and contractors working overseas for the government such as longshoremen, ship builders, ship repairers, harbor construction workers, employees at overseas military bases, employees working for US outside of country for public works, off shore drilling, and civilian employees of armed forces.

Worker's compensation is what type of insurance?

NO FAULT INSURANCE and varies by state

Longshoremen and Harbor Workers Comp Program doe NOT coveR

Seamen, employees of US government, state or foreign government employees, or those who injuries were caused solely by their own intoxication or international self harm

Combination Workmen's compensation programs

Some states allow a combination of insurance programs to cover employees injured on the job.

OSHA (Occupational Safety and Health Administration)

a government agency in the Department of Labor to maintain a safe and healthy work environment

State Insurance Fund

a quasi-public agency that provides workers' compensation insurance coverage to private and public employers and acts as an agent in workers' compensation cases involving state employees

Federal Black Lung Program

provides medical treatment and other benefits for respiratory conditions related to former employment in the nation's coal mines.

People not covered by workman's compensation or OSHA include

self employees (independent contractors), family members of farm owners that do not employee outside workers, some domestic workers, and some agricultural workers. Coast guard has own version of OSHA