Medical Insurance Chapter 15 Workers Compensation
Permanent disability (PD)
An illness or injury ( impairment of the normal use of a body part ) expected to continue for the lifetime of the injured worker that prevents the person from performing the functions of his or her regular occupation, therefore impairing his or her earning capacity.
Insurance Adjuster
An individual at the workers' compensation insurance carrier overseeing an industrial case, authorizing diagnostic testing and medical treatment, and communicating with the provider of medical care.
Work hardening
An individualized program of therapy using simulated or real job duties to build up strength and improve the worker's endurance to be able to work up to 8 hours per day. Sometimes work site modifications are instituted to get the employee back to gainful employment.
Accident
An unexpected happening, causing injury traceable to a definite time and place.
A form of self-insurance designed to serve a small manufacturing company is known as _______ insurance.
Captive
State compensation laws that require each employer to accept its provisions and provide for specialized benefits for employees who are injured at work are called
Compulsory Laws
A(n) ________is an unplanned and unexpected happening traceable to a definite time and place, causing injury ( damage or loss ) not due to any fault on the part of the person injured
Accident
An unexpected, unintended event that occurs at a particular time and place, causing injury to an individual not of his or her own making, is called a/an
Accident
Occupational illness ( or disease)
An abnormal condition or disorder caused by environmental factors associated with employment. It may be caused by inhalation, absorption, ingestion, or direct contact.
Federal Employees' Compensation Act (FECA)
An act instituted in 1908 providing benefits for on the job injuries to all federal employees.
Compromise and Release
An agreement arrived at, whether on or out of court, for setting a workers' compensation case after the patient has been declared permanent and stationary.
Medical service order
An authorization given to the physician, either written or verbal, to treat the injured or ill employee.
What is the minimum number of employees per business needed in your state for workers compensation statutes to become effective?
2 employees (state of arkansas)
Nondisability claim
A claim for an on the job injury that requires medical care but does not result in loss of working time or income.
Lien
A claim on the property of another as security for a debt. In litigation cases, it is a legal promise to satisfy a debt owed by the patient to the physician out of any proceeds received on the case.
Sometimes a patient is released to ____ work to effect a transition between the period of inactivity due to disability and return to full duty, especially when heavy work is involved.
Modified
Workers' compensation insurance
A contract that insures a person against on the job injury or illness. The employer pays the premium for his or her employees.
Occupational Safety and Health Administration (OSHA)
A federal agency that regulates and investigates safety and health standards in work locations.
Petition
A formal written request commonly used to indicate an appeal; also means any request for relief other than an application.
Second injury fund
A fund established under Workers' Comp laws in most states to help pay any increased compensation which may result when an employee with previous injury is injured again.
Fee Schedule
A list charges or established allowances for specific medical services and procedures. See also relative value studies (RVS)
Permanent and stationary (P and S)
A phrase used when a workers' compensation patient's condition has become stabilized and no improvement is expected. It is only after this declaration that a case can be rated for a compromise and release.
By Report
A report must be submitted with the claim when the notation "BR" follows the procedure code description. This term is sometimes seen in workers' compensation fee schedules.
Subsequent injury fund (SIF)
A special fund that assumes all or part of the liability for benefits provided to a worker because of the combined effect of a work related impairment and a preexisting conditions; also known as second-injury fund .
Explain third-party subrogation.
A third party is responsible for the injury (person is injured by an outside party).
Sequelae
Disease conditions after and usually resulting from a previous disease.
Name jobs that may not be covered by workers compensation insurance.
Domestic or casual employees, Laborers, Babysitters, Charity workers, Gardeners, Newspaper vendors or distributors
State compensation laws that may be accepted or rejected by the employer are known as
Elective Laws
ERISA
Employee Retirement Income Security Act
When an individual suffers a work-related injury or illness, the employer must complete and send a form called a/an____ to the insurance company and workers' compensation state offices, and if the employee is sent to a physician's office for medical care, the employer must complete a form called a/an_____, which authorizes the physician to treat the employee.
Employer's Report of Occupational Injury or Illness b. Medical Service Order
A(n) ________ evaluation of the work site may be performed, and modifications may be instituted to lessen the possibility of future injury
Ergonomic
If a workers' occupation takes a person into another state, most compensation laws are ________ and effective outside the state by either specific provisions or court decision.
Extraterritorial
A roofer takes his girlfriend to a roofing job and she is injured. She is covered under workers' compensation insurance.
False
A stamped physician's signature is acceptable on the Doctor's First Report of Occupational Injury or Illness form.
False
Name two kinds of statutes under worker's compensation.
Federal State
Waiting period (WP)
For disability insurance, the initial period of time when a disabled individual is not eligible to receive benefits even though unable to work; for workers' compensation, the days that must elapse before workers' compensation weekly benefits become payable. Also known as elimination period.
State five methods used for funding workers' compensation.
Monopolistic State or Provincial State Territorial Self insurers Competitive state fund Private Insurance Company
Injury
In a workers' compensation policy, this term signifies any trauma or damage to a body part or disease sustained, arising out of, and in the course of employment, including injury to artificial members and medical braces of all types.
Claims Examiner
In industrial cases, a representative of the insurer who authorizes treatment and investigates, evaluates, and negotiates the patient' s insurance claim and acts for the company in the settlement of claims; also known as claims adjuster, claims representative, and claims administrator.
A physician hired by the insurance company or appointed by the referee or appeals board to examine an injured worker and render an unbiased opinion regarding the degree of disability is referred to as a(n) _______
Independent medical evaluator ( IME ), Agreed medical evaluator ( AME ), Qualified medical evaluator ( QME )
When a physician treats an industrial injury, he or she must complete a First Treatment Medical Report or Doctor's First Report or Occupational Injury or Illness and send it to the following:
Insurance carrier Employer State workers' compensation office
IAIABC
International Association of Industrial Accident Boards and Commissions
Who can treat an industrial injury?
Licensed physician, osteopath, dentist or chiropractor
A(n) ________ expresses legal claim on the property of another for the payment of a debt.
Lien
The process of carrying on a lawsuit is called
Litigation
LHWCA
Longshoremen's and Harbor Workers' Compensation Act
MSDS
Material Safety Data Sheets
List five types of workers' compensation benefits.
Medical Treatments Temporary Disability indemnity Permanent Disability indemnity Death benefits for survivors Rehabilitation benefits
What are three types of workers' compensation claims and the differences among them?
Non-disability Claim - Person is injured or ill, is treated, and goes back to work. Temporary Disability Claim - Person is injured or ill and cannot work at his/her job and is off work for a period of time. Permanent Disability Claim - Person is injured or ill and cannot work, and the problem results in permanent injury or illness.
OSHA
Occupational Safety and Health Administration
Employers are required to meet health and safety standards for their employees under federal and state statutes known as the
Occupational Safety and Health Administration (OSHA) Act of 1970.
Any abnormal condition or disorder caused by exposure to environmental factor associated with employment, including acute and chronic illnesses or diseases that may be caused by inhalation, absorption, ingestion, or direct contact, is referred to as a(n) __________
Occupational illness
Maria Cardoza works in a plastics manufacturing company and inhales some fumes that cause bronchitis. Because this condition is associated with her employment, it is called a/an
Occupational illness
Ergonomic
Science and technology that seek to fit the anatomic and physical needs of the worker to the workplace.
Extraterritorial
State laws effective outside the state by either specific provision or court decision. In workers' compensation cases, benefits under the state law that apply to a compensable injury of an employee hired in one state but injured outside that state.
When an employee with a preexisting condition is injured at work and the injury produces a disability greater than what would have been caused by the second injury alone, the benefits are derived from a/an
Subsequent-Injury Fund or second injury fund
A(n) _________ report is sent to the insurance carrier after 2 to 4 weeks of treatment to give information on the current status of the patient.
Supplemental
Workers' compensation appeals board (WCAB)
The board that handles workers' compensation liens and appeals.
Adjudication
The final determination of the issues involving settlement of an insurance claim; also known as claim settlement.
Third-party subrogation
The legal process by which an insurance company seeks from a third party, who has caused a loss, recovery of the amount paid to the policyholder.
Deposition
The process of taking sworn testimony from a witness out of court. This is usually done by an attorney.
Temporary disability (TD)
The recovery period after a work-related injury during which the employee is unable to work and the condition has not stabilized; a schedule of benefits payable for the temporary disability.
Third-party liability
Third-party liability exists if an entity is liable to pay the medical cost for injury, disease, or disability of a person hurt during the performance of his or her occupation and the injury is caused by an entity not connected with the employer.
The legal words ____________ mean to substitute one person for another.
Third-party subrogation
If an individual seeks medical care for a workers' compensation injury from another state, the state's regulations are followed in which the injured person's claim was originally filed.
True
In a workers' compensation case, bills should be submitted monthly or at the time of termination of treatment, and a claim becomes delinquent after a time frame of 45 days.
True
The first thing an employee should do after he or she is injured on the job is to notify his or her employer or immediate supervisor.
True
When a patient arrives at a medical office and says he or she was hurt at work, you should verify insurance information with the benefits coordinator for the employer.
True
Sub rosa films
Videotapes made without the knowledge of the subject; used to investigate suspicious claims in workers' compensation causes
Rehabilitation in the form of retraining, education, and job guidance and placement to assist an injured individual in finding work is called ______ rehabilitation.
Vocational
After suffering an industrial injury, Mr. Fields is in a treatment program in which he is given real work tasks for building strength and endurance. This form of therapy is called
Work Hardening
An individualized program of therapy using simulated or real work task to build up strength and improve a workers' endurance toward a full day's work is called _______
Work hardening
WCAB
Workers' Compensation Appeals Board
Name the federal workers' compensation acts that cover workers.
Workmen's Compensation Law of the District of Columbia. Federal Coal Mine Health and Safety Act or Black Lung Benefits Act. Federal Employees' Compensation Act (FECA). Longshoremen's and Harbor Workers Compensation Act (LHWCA)
May an injured person appeal his or her case if he or she is not satisfied with the rating? If so, to whom does he or she appeal?
Yes. Workers' Compensation Appeals Board or Industrial Accident Commission
State compensation laws that require each employer to accept its provisions and provide for specified benefits are ______ laws
a: compulsory
AME
agreed medical evaluator
An abnormal condition caused by exposure to environmental factors associated with employment is termed a(n)...
b: occupational illness
BR
by report
The statutes for workers' compensation laws fall under ____ compensation laws...
c: federal and state
C&R
compromise and release
The reason for workers' compensation laws is to...
d: (all of the above) ensure a prompt return to work of any injured or ill employee/provide income to the injured or ill worker/encourage maximum employer interest in safety
A proceeding during which an attorney questions a witness who answers under oath but not in open court is called a/an
deposition
FECA
federal employees compensation act
IME
independent medical evaluator
The legal promise of a patient to satisfy a debt to the physician from proceeds received from a litigated case is termed a/an
lien
ND Claim
non disability claim
P & S
permanent and stationary
PD
permanent disability
QME
qualified medical evaluator
ROM
range of motion
What waiting period must elapse in your state before workers compensation payments begin?
seven days (state of arkansas)
SIF
subsequent injury fund
TD
temporary disability
Weekly temporary disability payments are based on
the employee's' earnings at the time of the injury or illness.
Who pays the workers' compensation insurance premiums?
the employer
When fraud or abuse is suspected in a workers' compensation case, the physician should report the situation to
the insurance carrier
When an industrial case reaches the time for rating the disability, this is accomplished by what state agency?
the state's industrial accident commission or workers' compensation board
WP
waiting period
What is the time limit in your state for submitting the employers and/or physicians report on an industrial accident
within 10 days from notice of injury