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Workers' Compensation Guidelines

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					              Ventura County Schools Self Funding Authority
                      Workers’ Compensation
                                  Guidelines




                                                 Version 1.1
                                                  August 2012




Prepared by YORK Risk Services Group, Inc.
                                                                               Table of Contents
Introduction ......................................................................................................................................4
Self-funded program ........................................................................................................................4
Contacts............................................................................................................................................4
Information and Assistance Office: .................................................................................................6
What is Workers’ Compensation? ...................................................................................................7
No-fault, mandatory coverage .........................................................................................................7
What is not covered?........................................................................................................................7
Eligible employees, volunteers, and ROP students .........................................................................7
Workers’ compensation benefits......................................................................................................8
 Medical Care ............................................................................................................................... 8
 Temporary Disability Benefits .................................................................................................... 9
 Permanent Disability Benefits .................................................................................................. 10
 Vocational Rehabilitation Services ........................................................................................... 10
 Supplemental Job Displacement Benefits ................................................................................. 10
 Death Benefits ........................................................................................................................... 10
Supplementing Temporary Disability Benefits .............................................................................11
Overview ........................................................................................................................................11
Industrial Accident Leave ..............................................................................................................11
Accrued Sick Leave and Accrued Vacation Leave........................................................................12
Extended Sick Leave......................................................................................................................12
39-Month Rehire List .....................................................................................................................13
Transitional Duty ...........................................................................................................................13
Pre-Designating a Doctor...............................................................................................................14
Employees who pre-designate .......................................................................................................14
Employees who do not pre-designate ............................................................................................14
Claims Filing Responsibilities .......................................................................................................15
Employees ......................................................................................................................................15
Employers ......................................................................................................................................16
Oc-Med Program ...........................................................................................................................18
Injury Prevention Program .............................................................................................................18
Denied Claims ................................................................................................................................20
Appendix A ....................................................................................................................................21
Appendix B ....................................................................................................................................23
 August 2012 ed.
                                         VCSSFA Workers’ Compensation Guidelines                                                          Page 2
Appendix C ....................................................................................................................................27
Appendix D ....................................................................................................................................29
Appendix E ....................................................................................................................................31
Appendix F.....................................................................................................................................33
Appendix G ....................................................................................................................................38
Appendix H ....................................................................................................................................43




 August 2012 ed.                        VCSSFA Workers’ Compensation Guidelines                                                        Page 3
                                                                    Introduction
       The Ventura County Schools Self Funding Authority (VCSSFA) is a Joint Powers
       Authority (JPA) that provides its member agencies with Workers’ Compensations
       coverage and services through a self insured Workers’ Compensation Program.
       VCSSFA utilizes an outside company, YORK Risk Services Group, Inc. to administer
       the benefits.

       These guidelines were prepared by YORK Risk Services Group, Inc. to help members
       understand the Workers’ Compensation Program that VCSSFA offers and the procedures
       to follow when an employee is injured or becomes ill as a result of work-related
       activities.  All members are encouraged to read this publication and share it with
       administrative leaders and supervisors.


Self-funded program


       The members of VCSSFA have elected to self-fund its workers’ compensation liability
       rather than purchase an insurance policy. This means that medical bills and all other
       benefits are paid directly from VCSSFA Funds. Medical treatment associated with work
       related injuries is provided through the JPA’s Medical Provider Network (MPN),
       WellComp.


                           There is no insurance company involved.

       VCSSFA’s greatest concern is to see that every employee receives the best medical care
       and attention available in order to ensure rapid recovery and return to work. The State of
       California supervises both the amount of benefits available under workers’ compensation
       and the distribution on all payments.


Contacts

       Any questions or inquiries related to the Member Agency’s workers’ compensation
       coverage through VCSSFA should be directed to the staff of the JPA. All employee
       questions and inquiries about workers’ compensation or specifically about a claim should
       be directed to the claims staff at YORK Risk Services Group, Inc. If an employees feels
       he/she needs additional information or clarification, the employee can also the State of
       California Division of Workers Compensation.


August 2012 ed.
                          VCSSFA Workers’ Compensation Guidelines                         Page 4
                                                                   CONTACTS

Ventura County Schools Self Funded Authority
Elizabeth Atilano, Executive Director
5189A Verdugo Way
Camarillo, CA 93012
805.383.1969
805.383.1971 fax

Claims Administrator

YORK Risk Services Group, Inc.
P.O. Box 619079
Roseville, CA 95661
805.288.4100
866.548.2637 fax


Jody Gray, President
714.620.1336
Jody.gray@yorkrsg.com

Devora Brainard, V.P. Managed Care
WellComp MPN and Utilization Review
951.231-6825 x 225
Devora.brainard@yorkrsg.com

Winston B. McCathan, Manager
805.288.4062
Winston.mccathan@yorkrsg.com

Claudia McKay, Medical Only/Future Medical Examiner
Claudia.mckay@yorkrsg.com
805.288.4084

Dorothy Davis , Sr. Claims Examiner
Dorothy.davis@yorkrsg.com
805.288.4071


August 2012 ed.          VCSSFA Workers’ Compensation Guidelines         Page 5
Sylvia Pulido, Sr. Claims Examiner
Sylvia.pulido@yorkrsg.com
805.288.4073

Sheryl Pedersen, Claims Examiner
Sheryl.pedersen@yorkrsg.com
805.288.4072

Suzanne Rios, Claims Examiner
Suzanne.rios@yorkrsg.com
805.288.4076




Information and Assistance Office:

Worker’s Compensation Appeals Board
1901 N. Rice Rd Suite 200
Oxnard, CA 93030
Information and Assistance Officer
Tina Urias
805.484.3528
800.736.7401
Direct Line: 805.485.3588
Fax: 805.485.6339




August 2012 ed.          VCSSFA Workers’ Compensation Guidelines   Page 6
            What is Workers’ Compensation?

No-fault, mandatory coverage

       Workers’ Compensation is a state-mandated coverage in California for all eligible
       employees who are injured or become ill as a result of their employment. An employee
       could be injured in one incident while at work or through repeated exposures at work.

       Workers’ Compensation is a no-fault system, meaning that injured employees need not
       prove the injury was someone else's fault in order to receive workers' compensation
       benefits for an on-the-job injury.

       The workers' compensation system is based on a trade-off between employees and
       employers – employees should promptly receive the statutory workers' compensation
       benefits for on-the-job injuries, and in return, the workers' compensation benefits are the
       exclusive remedy for injured employees against their employer.



What is not covered?

       Typically, workers’ compensation does not cover injuries that occur outside of work, or
       are due to personal illness, self-inflicted injuries, intoxication, or personal disputes.



Eligible employees, volunteers, and ROP students

       The VCSSFA workers compensation program applies only to the member agencies’
       employees and substitutes, volunteers, and students in a Member Agency-authorized
       Regional Occupational Program (ROP) provided that the following requirements are met:

       Employees and Substitutes

                 The injured or ill person must be a full-time or part-time employee – i.e.,
                  registered in the Member Agency’s payroll system. Contractors, consultants,
                  vendors, and other third parties are generally covered by their own employers’
                  workers’ compensation program.

                 The injury or illness must be sustained within the course and scope of the person’s
                  employment.

August 2012 ed.               VCSSFA Workers’ Compensation Guidelines                         Page 7
       Volunteers and ROP Students

                 The VCSSFA workers compensation program also covers volunteers and students
                  in a Member Agency-authorized Regional Occupational Program (ROP) who are
                  not paid a salary.

                 The injury or illness must be sustained within the course or scope of the volunteer
                  or ROP duties.

       For the purpose of workers' compensation coverage, a volunteer is defined as a person
       rendering services to the Member Agency where the Member Agency has control and
       direct supervisory responsibility over the manner and result of the services rendered; and
       the volunteer receives no remuneration for such services other than meals, transportation,
       lodging, or reimbursement for incidental expenses, if appropriate.



Workers’ compensation benefits

       There are six basic types of workers' compensation benefits available, depending on the
       nature, date, and severity of the worker's injury: (1) medical care, (2) temporary disability
       benefits, (3) permanent disability benefits, (4) vocational rehabilitation services for
       injuries that occurred before January 1, 2004, (5) supplemental job displacement benefits
       for injuries that occurred after January 1, 2004, and (6) death benefits.

                  Medical Care

                  Injured workers are entitled to receive all medical care reasonably required to cure
                  or relieve the effects of the injury, with no deductible or co-payments by the
                  injured worker. For dates of injury on or after Jan. 1, 2004, an injured worker is
                  limited to 24 chiropractic, 24 occupational therapy, and 24 physical therapy visits.

                  The JPA has established a Medical Provider Network (MPN), WellComp, for the
                  provision of all medical care and medical services related to a work related injury
                  occurring on or after October 1, 2005. All employees, volunteers and ROP
                  Students are covered by the MPN. However, if the employee has notified the
                  employer in writing prior to the injury that he or she has a "personal physician" on
                  the Personal Physician Designation form (see Appendix A), the employee may be
                  treated by that physician from the date of injury. A “personal physician” for
                  workers’ compensation must be a Medical Doctor (M.D.) or Doctor of
                  Osteopathy (D.O.), or group comprised of the same who has limited his or her
                  practice of medicine to general practice or who is a board-certified or board-
                  eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner.
                  Further, the personal physician must be the employee’s regular physician who has
                  previously directed the employee’s medical treatment and retains the employee’s


August 2012 ed.               VCSSFA Workers’ Compensation Guidelines                          Page 8
                      medical records and medical history.           A personal physician cannot be a
                      chiropractor or an acupuncturist.

                      Following an injury and employee will be directed by his/her employer to an
                      initial care provider within the WellComp MPN and can thereafter change
                      providers by selecting another provider within the WellComp MPN. The MPN
                      includes providers from all specialties including chiropractic medicine and
                      acupuncture. The list of participating providers can be accessed via internet at
                      www.wellcomp.net or an employee can receive a hard-copy of the most current
                      list of providers by contacting YORK Risk Services Group, Inc.

                      Temporary Disability Benefits

                      Those workers unable to return to work within three days1 are entitled to
                      temporary disability benefits to partially replace wages lost as a result of the
                      injury (workers’ compensation benefits are generally designed to replace two-
                      thirds of the lost wages, up to a statutory maximum). Eligibility for temporary
                      disability benefits is determined by the authorized treating physician. An
                      employee may not be eligible for temporary disability benefits if transitional duty
                      is available that accommodates any temporary restrictions imposed by the treating
                      physician.

                      After the day of injury, eligibility for temporary disability benefits begin on the
                      fourth calendar day the employee cannot work as authorized by the employee’s
                      treating physician within the WellComp MPN, unless a pre-approved Personal
                      Physician Designation form is on file – see Appendix A). By law, the three-day
                      period is waived if the injury results in immediate hospitalization or the employee
                      is off work for more than 14 days.

                      Note that the member agency, in accordance with the Education Code and its own
                      memorandums of understanding (MOU) will supplement temporary disability
                      benefits so that injured workers receive full pay during Industrial Accident Leave,
                      including the first three days following the injury. If leave extends beyond 60
                      working days employees are entitled to supplement the temporary disability
                      benefits with regular sick leave, extended sick leave, and other benefits depending
                      on their position and the Member Agency MOU. (See “Supplementing Temporary
                      Disability Benefits” below)




1
 California Labor Code §4652. Temporary disability indemnity is not recoverable for the first three days after the
employee leaves work as a result of the injury unless temporary disability continues for more than 14 days or the
employee is hospitalized as an inpatient for treatment required by the injury.

    August 2012 ed.               VCSSFA Workers’ Compensation Guidelines                                   Page 9
                      Permanent Disability Benefits

                      Injured workers who are permanently disabled are entitled to receive permanent
                      disability benefits. A worker who is determined to have a permanent total
                      disability receives the temporary disability benefit for life.

                      A worker determined to have a permanent partial disability receives partial
                      benefits for a certain period. The length of the period is based on the worker’s
                      medical condition, date of injury, age when injured, and occupation, and loss of
                      future earning capacity.2

                      Vocational Rehabilitation Services

                      Vocational rehabilitation services are not available for injuries on or after Jan. 1,
                      2004. For injuries prior to that date, injured workers who are unable to return to
                      their former type of work are entitled to vocational rehabilitation services if these
                      services can reasonably be expected to return the worker to suitable gainful
                      employment. Vocational rehabilitation does not apply to injury after Jan. 1, 2004.

                      Supplemental Job Displacement Benefits

                      This is a nontransferable voucher for education-related retraining or skill
                      enhancement, or both, payable to a state approved or accredited school if the
                      worker is injured on or after Jan. 1, 2004. The employee must have suffered a
                      permanent disability and the employer does not offer modified or alternative
                      work.

                      Death Benefits
                      In the event a worker is fatally injured, reasonable burial expenses, up to $5,000,
                      are paid. In addition, the worker's dependents may receive support payments for a
                      period of time, depending on the extent of their dependency, subject to a statutory
                      maximum.




2
    See California Labor Code §4658 for the period of payment based on the percentage of disability.

    August 2012 ed.               VCSSFA Workers’ Compensation Guidelines                              Page 10
                                  Supplementing Temporary
                                         Disability Benefits
Overview

       Temporary disability benefits are one of the six workers’ compensation benefits
       described in the previous section. Temporary disability benefits provide two-thirds of the
       employee’s normal salary up to maximum amount determined by the State of California.
       Temporary disability benefits continue through the period of disability up to a maximum
       number of weeks according to the date of injury.

       Employees of public educational institutions who are subject to the California Education
       Code are entitled to additional benefits during a workers’ compensation leave that vary
       for each agency depending on the terms of the its MOU and on past administrative
       practice. However, in general, during the employee’s entitlement to temporary disability,
       there are different types of supplemental benefits provided to the employee to increase
       the employee’s compensation. The timeline below is an example of the continuum of
       supplemental benefits but will vary depending on the agency’s MOU and past
       administrative practice.


               Industrial Accident Leave     Sick Leave Vacation            Ext. Sick Leave      39-rehire

         1st day            60                                         100 days for classified       39
         absent            days                                        employees; 5 months for      months
                                                                       certificated employees*

               Family Medical Leave Act runs concurrently (12 weeks)

           *




Industrial Accident Leave

       Once a claim is pending or accepted, the Member Agency continues to pay the employee
       a regular payroll checks during Industrial Accident Leave. Industrial Accident Leave is
       the 60-day period following the employee’s first day of absence. YORK Risk Services
       Group, Inc. will reimburse the Member Agency out of the VCSSFA funds for the
       workers’ compensation temporary disability benefits included in the employee’s salary.


August 2012 ed.                VCSSFA Workers’ Compensation Guidelines                                Page 11
       Industrial Accident Leave applies for 60 working days for any one accident or illness
       during any one fiscal year, except that when an industrial accident or illness leave
       overlaps into the next fiscal year, the employee is entitled to only the amount of unused
       leave due for the same injury or illness. Industrial Accident Leave is not cumulative and
       begins on the first day of absence. Employees are eligible to receive Industrial Accident
       Leave at the beginning of the second month following their probation period.



Accrued Sick Leave and Accrued Vacation Leave

       Once the Industrial Accident Leave has run, the Member Agency applies accrued and
       vested sick leave and vacation days (if applicable) to supplement temporary disability
       benefits in order to provide the employee with a full paycheck. The Member Agency
       issues the employee a full check, and YORK reimburses the Member Agency out of
       VCSSFA funds for the workers’ compensation portion.

       An employee, who is receiving temporary disability payments and supplemental sick
       leave or vacation leave benefits, is considered to be on regular pay status for purposes of
       application of all Member Agency personnel policies except completion of the
       probationary period.




Extended Sick Leave

       If an employee is not medically able to reassume job duties after exhausting sick leave
       and other selected leave accruals, the employee is then eligible to receive Extended Sick
       Leave. Due to the substantial variations from member agency to member agency,
       extended sick leave will not be detailed. During the extended sick leave period, the
       employee is entitled to receive both the workers’ compensation temporary disability and
       the benefits the member agency are obligated to pay in accordance with its extended sick
       leave policy. Should the combination of benefits exceed the employee’ regular earnings,
       YORK will coordinate the payments with the member agency to avoid an overpayment.




August 2012 ed.           VCSSFA Workers’ Compensation Guidelines                         Page 12
39-Month Rehire List

       If the employee continues to be off work beyond the period of extended sick leave, and
       the employee is not placed in another position, the employee will be placed on a re-
       employment list for a period of 39 months.

       Prior to the actual termination of benefits, the member agency will engage in the
       “interactive process” to identify if the employee’s disability can be accommodated
       pursuant to the rules and regulations promulgated by the California Department of Fair
       Employment and Housing (DFEHA) and the Americans With Disabilities Act (ADA).
       Should the member agency require assistance with this process, they can contact YORK.

       When available during the 39-month period, the employee shall be employed in a vacant
       position in the class of his or her previous job over all available candidates subject to any
       seniority regulations.

       An employee, who is on the 39-Month Rehire List, has been medically released for return
       to work, and who does not accept an appropriate position, will be dismissed.


Transitional Duty

       If medically feasible, member agencies will attempt to place an injured worker who is
       unable to return to regular duty in a transitional work environment if it is suggested by
       the treating physician and can be practically accommodated by the member. Transitional
       Duty can consist of modification to existing job responsibilities or alternate temporary
       assignment that can accommodate the temporary restrictions.

       The JPA recognizes the need to support the recovery of employees should they suffer a
       work-related injury or illness or develop an occupational disease. It is well established
       that recovery is accelerated when the employee continues to work. Based on this
       principle, the JPA strongly supports appropriate return-to-work in a transitional position.

       Member agencies can contact YORK for ideas on how to effectively put together a
       transitional duty program.




August 2012 ed.            VCSSFA Workers’ Compensation Guidelines                          Page 13
                                Pre-Designating a Doctor

       If an employee completes the Personal Physician Form (Appendix A) before the injury or
       illness takes place, the employee can use his or her personal physician to treat the injury
       or illness. This is called “pre-designating” the employee’s personal physician.


Employees who pre-designate
       If properly filed prior to an injury, an employee may treat immediately with their
       “personal physician” for workers’ compensation as long as he or she is a Medical Doctor
       (M.D.) or Doctor of Osteopathy (D.O.), or group comprised of the same who has limited
       his or her practice of medicine to general practice or who is a board-certified or board-
       eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. Further,
       the personal physician must be the employee’s regular physician who has previously
       directed the employee’s medical treatment and retains the employee’s medical records
       and medical history. A personal physician cannot be a chiropractor or an
       acupuncturist.

       When releasing the employee to secure medical care, the member agency should provide
       the employee with the “Treatment Authorization from” found in Appendix C to provide
       to his or her pre-designated physician.


Employees who do not pre-designate

       If an employee does not pre-designate a doctor, the employee is directed to an initial care
       provider within the WellComp MPN. Each member agency works with YORK to select
       an initial care provider (s). Should the agency require assistance or desire to explore
       adding a new provider to the MPN, they should contact YORK. Each member agency
       should provide an injured employee with the “Treatment Authorization form” found in
       Appendix C when referring the employee for care.

       After the initial medical evaluation, the employee can switch to an appropriate treating
       physician participating in the WellComp MPN of the employee’s choice if the employee
       still needs medical care. The new doctor must be the appropriate specialist to treat the
       nature of the injury or illness. The employee can obtain assistance finding the
       appropriate treating physician in the WellComp Network by contacting the WellComp
       Patient Services Department at (800) 544-8150. Alternatively, the employee can select
       their own physician by accessing the WellComp provider directory at www.wellcomp.net
       and requesting a hard copy of the directory by contacting YORK or the WellComp
       patient services Department.


August 2012 ed.            VCSSFA Workers’ Compensation Guidelines                          Page 14
                          Claims Filing Responsibilities

Employees

           If an employee is hurt on the job, the employee should:

               1. Report the injury to the employee’s supervisor immediately. If the injury or
                  illness developed over time, the employee must report it as soon as he or she
                  learns that it was caused by the employee’s job.

               2. Get emergency treatment if needed. If it is a medical emergency, the employee
                  should go to an emergency room right away. The employee should tell the health
                  care provider that the injury or illness is job-related.

               3. Fill out and sign the employee section of the claim form entitled Employee’s
                  Claim for Workers’ Compensation Benefits (see Department of Workers’
                  Compensation (DWC) Form 1 in Appendix B) and give the completed form to his
                  or her supervisor.

               4. The supervisor fills out and signs the employer portion of the claim form and
                  directs it internally so that it gets routed to VCSSFA claims administrator, YORK
                  Risk Services Group, Inc.

                      a. YORK must decide within 90 days whether to accept or deny the claim. If
                         YORK accepts the claim, it means that YORK agrees that the employee’s
                         injury is covered by workers’ compensation. If YORK denies the claim,
                         the employee has the right to challenge the decision.

               5. Within one working day after the employee files the claim form, YORK, on
                  behalf of the member agency, is required by the California Labor Code to
                  authorize medical treatment3 up to a maximum of $10,000 while the employee’s
                  claim is being investigated following notice or service of the claim form upon the
                  Member Agency. If YORK does not respond to a request for authorization in a
                  timely manner as outlined in Labor Code section 4610, the employee should
                  notify the Business Services Office or their claims contact at YORK.

               6. If an employee has filed a claim, the employee can call YORK for specific
                  questions about his or her filed workers’ compensation claim.




3
 In accordance with the ACOEM Guidelines or any other nationally recognized medical guide established for the
care of industrial injuries.

    August 2012 ed.            VCSSFA Workers’ Compensation Guidelines                                 Page 15
           7. The employee should provide his or her supervisor with all physical therapy status
              sheets and work status reports. Supervisors should immediately forward this
              information internally based on the member agency’s protocols.

           8. If the employee pays a bill, the employee should photocopy the receipt and
              forward a copy to YORK for reimbursement. Similarly, if an injured employee
              receives a bill, it should be forwarded directly to YORK.

           9. The employee should keep his or her supervisor informed of the status of his or
              her injury and claim.

           10. The employee should try to schedule doctor appointments and/or physical therapy
               visits after work. Any doctor appointments or physical therapy treatments taken
               during regular work hours will result in a full day being deducted from the 60
               days of Industrial Accident Leave.


Employers

       If an employee reports an injury or illness to his or her supervisor, the employer must:

           1. Obtain needed medical care for the injured employee right away.

                  a. When an employee reports an injury on a weekday during business hours
                     and is able to transport him or herself:

                          1. Complete a Treatment Authorization Form (Appendix C).

                          2. Refer the employee to the designated WellComp initial care
                             provider

                          3. If the employee has pre-designated a personal physician and it is
                             not an emergency, the employee should go to his or her personal
                             physician.

                  b. If an employee is in need of immediate medical treatment, call 911. No
                     treatment authorization is needed.

                  c. Provide the injured or ill worker with DWC Form 1 (Appendix B) and the
                     WellComp Informational Pamphlet (Appendix H) directly or send them by
                     first class mail to the employee’s home. The injured or ill employee must
                     be given the form within one business day of the employee’s report of the
                     injury. The employee completes the employee section of DWC Form 1.

                  d. Once the employee returns the DWC 1, the employer must complete the
                     following items:


August 2012 ed.            VCSSFA Workers’ Compensation Guidelines                         Page 16
                      i. Item 9 –Employer: Insert your agency’s official name

                     ii. Item 10 – Address: Insert your agency’s official address

                     iii. Items 11-13: Insert the applicable claim information.

                     iv. Item 16 – Signature: Sign the form.

                     v. Item 17 – Title: Insert your title.

                     vi. Item 18 – Insert your telephone number.

           2. Complete the Employer’s Report of Occupational Injury or Illness (Appendix D)
              and fax of mail to YORK. Member agencies can also report claims to YORK via
              their web-based reporting portal. Contact YORK for a log-in and password.

           3. Mail or fax a copy of the completed Employee’s Claim for Workers’
              Compensation Benefits Form (DWC Form 1) (Appendix B) to YORK. The
              submission of this form does not mean that the claim is automatically accepted.

           4. Report any change in an injured employee’s status to YORK immediately. A
              change in status would be a change in lost time from work, return to work, or a
              physician’s report recommending modified work duty.

           5. Forward any physical therapy status sheets and work status reports received from
              the employee to YORK.

           6. Work with YORK to provide the employee with transitional duty if the employee
              is unable to return to full duties following the injury.

       Member agencies should also ensure that posters giving notice of workers’ compensation
       benefits are posted in conspicuous locations. A sample poster is shown in Appendix F.
       YORK will also contact member agencies to secure proof of the employee’s actual
       earnings. The member agency can provide a computerized or electronic summary of
       earnings or use the Wage Statement Form in Appendix E. It is important that these
       posting notices contain the language and information regarding use and access to the
       WellComp MPN.

       As the employer, member agency’s will need to cooperate with YORK and provide them
       with the information necessary to investigate questionable claims and to efficiently and
       promptly provide the benefits to which legitimately injured employees are entitled.
       Should a member agency suspect that an employee or medical provider is intentionally
       misconstruing facts in order to get benefits that they would not otherwise be entitled,
       immediately notify YORK so that they can initiate a report to the proper authority for
       suspected Fraud.




August 2012 ed.           VCSSFA Workers’ Compensation Guidelines                      Page 17
Investigations & Sub-rosa
California Code of Regulations Section 10109(a) states that in order to comply with
requirements of the Labor Code and the Administrative Director's regulations, a Claims
Administrator must conduct a reasonable and timely investigation upon receiving notice or
knowledge of an injury or claim for a workers' compensation benefit. The Department of
Insurance also requires that examiners be trained on an annual basis to identify suspected
insurance fraud, making your YORK examiner the most qualified to a file for a surveillance level
investigation. When your examiner refers the files on your behalf, it limits the District’s
exposure to possible civil claims of malicious prosecution, slander or libel due to a violation of
Civil Code Section 1708.8.



                                                         Oc-Med Program

Injury Prevention Program

       The members of Ventura County Schools Self-Funding Authority currently participate or
       have the ability to utilize The OC-MED Injury Prevention Program. The goal of Injury
       Prevention and Management Services is to reduce injuries and their related costs for all
       members and to provide pre and post injury support to employees. The OC-Med
       Program and Ergonomic Intervention Services are designed to help provide a safe and
       healthy work environment, create an incentive for personal responsibility, provide cost
       savings and increase employee morale by potentially changing “work place perceptions”.


       The VCSSFA Risk Program Dept. administers the OC-MED Injury Prevention Program,
       with services provided in close coordination with approved program vendors. The goal of
       The OC-MED Injury Prevention Program is designed not only to reduce the costs
       associated with injuries and workers’ compensation claims, but even more significant
       implications for efficiency, productivity, safety and health concerns amongst employees.
       To bring new ideas to the workplace, meet Cal/OSHA Guidelines & Standards and to
       learn good safety and health practices that employees will be able to implement not only
       at the workplace, but in everyday life, as well.


       The services offered through OC-MED Injury Prevention Program vary based upon the
       specific needs of each referral and may include but are not limited to the below list:

       1.   Ergonomic Jobsite Analysis:
            This entails the physical therapist visiting the work site in question to examine the
            employee’s job responsibilities, their work environment, worker techniques and
            related contributing issues. The purpose is to identify the various risk factors that are
            causing the injury or potential injury, and the associated costs, and then to provide
            corrective recommendations in a comprehensive report. Finally, there will be close
August 2012 ed.             VCSSFA Workers’ Compensation Guidelines                          Page 18
            integration with VCSSFA Risk Program Coordinator, the provider of Ergonomic
            Evaluation and the Risk Manager to discuss and suggest viable changes needed for
            the employee.

       2.    Ergonomic Educational Program:
            On-site educational programs will cover topics to enhance a successful injury
            prevention and management process. For example, specific target sessions for
            problems relating to workplace fatigue, providing preventative stretching exercises,
            ergonomic team set-up, a proactive attitude in management, and introduction of the
            "Professional Industrial Athlete" concept to the employee.

       3.    Follow-up Sessions:
            Many of the client interventions detailed above will require closely monitored follow-
            up and subsequent on-site work site visits to ensure objective, successful results. The
            client interventions available in the Injury Prevention and Management portion of the
            OC-Med Program are designed to be initiated by both the client and VCSSFA on a
            Post and Pre-Injury basis. All client interventions will be scheduled and monitored
            by VCSSFA Risk Program Coordinator.

       4.    Training Sessions:
            On-site Group Training Programs are also available and coordinated with the Risk
            Program Coordinator. Training is carefully customized for the occupation and the job
            responsibilities of those employees being trained.

                      A.   Warm-Up Program
                      B.   Lumbar / Abdominal Core stabilization Program
                      C.   Stretching
                      D.   Materials Handling
                      E.   Maintenance, Grounds & Warehouse
                      F.   Custodial
                      G.   Para Educators
                      H.   Nutritional Services
                      I.   Office Workers
                      J.   Transportation

       Sample Referral and OC-MED Injury Prevention Program informational needs are found
       in Appendix G along with assessment follow-up forms.
       If you may have any questions, please contact Russ Olsen, Risk Program Coordinator for
       VCSSFA at 805.383.1970. Alternatively, you may e-mail to rolsen@vcoe.org.




August 2012 ed.             VCSSFA Workers’ Compensation Guidelines                        Page 19
                                                              Denied Claims
       If a claim is denied, YORK will confer with the member agency first and then will mail a
       letter to the employee’s home explaining why the claim has been denied. Copies of the
       letter will also be sent to the Member Agency. If the employee is still disabled but it is
       not work related then the member agency needs to provide the employee with the regular
       benefits that they would be entitled to absent a work related injury.




August 2012 ed.           VCSSFA Workers’ Compensation Guidelines                        Page 20
                                                             Appendix A




                  Personal Physician Form




August 2012 ed.
                   VCSSFA Workers’ Compensation Guidelines          Page 21
                            PREDESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such
injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or
medical group if: your employer offers group health coverage; the doctor is your regular physician, who
shall be either a physician who has limited his or her practice of medicine to general practice or who is a
board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner,
and has previously directed your medical treatment, and retains your medical records; your "personal
physician" may be a medical group if it is a single corporation or partnership composed of licensed
doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing
comprehensive medical services predominantly for non-occupational illnesses and injuries; prior to the
injury your doctor agrees to treat you for work injuries or illnesses; prior to the injury you provided your
employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-
related injury or illness, and (2) your personal doctor’s name and business address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a
doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements
are met.

NOTICE OF PRE-DESIGNATION OF PERSONAL PHYSICIAN
Employee: Complete this section.

To: ____________________________ (name of employer) If I have a work-related injury or illness, I
choose to be treated by:
_______________________________________________________________________
(Name of doctor)(M.D., D.O., or medical group)
______________________________________________________(street address, city, state, ZIP)
___________________________________________(telephone number)

Employee Name (please print):
Employee’s Address:
________________________________________________________________________
Employee’s Signature_______________________________________________Date:_____________

Physician: I agree to this Pre-designation:
Signature:____________________________________________________Date:__________
(Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form, however, if the physician or designated employee of the
physician or medical group does not sign, other documentation of the physician’s agreement to be pre-
designated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).
Title 8, California Code of Regulations, section 9783.
    (Optional DWC Form 9783 March 1, 2007 )




 August 2012 ed.
                              VCSSFA Workers’ Compensation Guidelines                               Page 22
                                                             Appendix B




                  California Department of
                  Workers’ Compensation
                                   Form 1




August 2012 ed.
                   VCSSFA Workers’ Compensation Guidelines          Page 23
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 24
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 25
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 26
                                                                Appendix C




                  Treatment Authorization Form




August 2012 ed.
                      VCSSFA Workers’ Compensation Guidelines          Page 27
            ____________________School District
Employer: ___________________________________                                                Date ________________

Date of Injury: ___________________                                      Time In __________ Time Out __________

Dr. ______________________________ Address _______________________________________________

We are sending __________________________________                  ____________________ to you for consultation
                    (Injured Employee)                                 (Title)
and evaluation in accordance with the terms of the Workers’ Compensation laws. Should you find that the
injured worker requires treatment, please contact York’s Utilization Review Department at (951) 892-7200 for
authorization.
                                                                 _______________________________________
                                                                  Department Referral (Signature)

Please submit your Doctor’s First Report to: YORK Risk Services Group, Inc., PO Box 619079,
Roseville, CA 95661

 Please indicate below whether or not the employee will be able to engage in his/her usual and customary
 occupation during the time of this injury. Should the employee be temporarily disabled from said
 occupation, we request you provide any and all restrictions causing him/her to be unable to perform
 his/her usual and customary duties. The employer provides modified light duty, when feasible, until
 he/she can return to his/her usual and customary duties, or is declared permanent and stationary.

      Is working and not disabled from work.

       Is DISABLED UNTIL _____________________________

      Is released to return to regular work on _______________________

      Is released to return to modified work on ______________________ WITH RESTRICTIONS of:

      No pushing, pulling or lifting over              10 lbs.     15 lbs.       25 lbs.      50 lbs.       _____ lbs.

      No soiling or wetting of dressing and/or wound.

      Limited use of         Right              Left                  Arm         Shoulder         Hand           Wrist

      Limited                Standing           Walking               Sitting     Stooping          Bending

      No climbing            Stairs             Ladders               No overhead work                  Sitting work only

   ALL MODIFIED WORK INCLUDES THE RESTRICTION OF NO SPORTS ACTIVITY.

       Is scheduled to return to physician on ___________________ at __________________.

       Anticipated duration of the MODIFIED status above is __________ day’s __________ weeks.


       _____________________________________________________                               _______________________
       Physician’s Signature                                                               Date



August 2012 ed.
                            VCSSFA Workers’ Compensation Guidelines                             Page 28
                                                            Appendix D




                          Employer’s Report of
                  Occupational Injury or Illness




August 2012 ed.   VCSSFA Workers’ Compensation Guidelines     Page 29
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 30
                                                            Appendix E




                       Wage Statement




August 2012 ed.
                  VCSSFA Workers’ Compensation Guidelines          Page 31
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 32
                                                                Appendix F




                  Workers’ Compensation Notice
              and OSHA Safety Notice Posters




August 2012 ed.
                      VCSSFA Workers’ Compensation Guidelines          Page 33
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 34
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 35
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 36
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 37
                                                               Appendix G




                  OC-Med Referral Information
                            and Ergonomic
                       Assessment Forms




August 2012 ed.      VCSSFA Workers’ Compensation Guidelines          Page 38
                  OC-Med Injury Prevention Program Referral Information

Below is information that is needed and useful in order for the OC-Med Risk Program
Coordinator to schedule an Ergonomic Intervention or an Ergonomic Training Presentation.

Individual Ergonomic Intervention:

      Name of employee
      Position/Job Title
      Job responsibilities
      Location
      Phone number and extension – work, home, cell
      Best time to contact employee
      E-mail address
      Reason for scheduling an intervention; new workstation, remodel, new or change of position,
       complaints and or issues
      What are the issues or problems the employee believes are associated with his workstation and or
       job duties
      Pre Injury Intervention or Post Injury Intervention
      If Post Injury – nature of injury, diagnosis, work restrictions, work status
      History of claims filed
      Urgency of the request
      Contact person to schedule the intervention (employee, supervisor, manager)
      Contact person’s phone number
      Request of ergonomic equipment/supplies
      Authorization for purchase of an ergonomic equipment/supplies
      Employee requested ergonomic evaluation
      How many workstations/worksites does the employee have
      Has a previous ergonomic intervention been conducted
      Has employee been provided with ergonomic equipment/supplies through a previous intervention
      Has the employee requested a particular item; such as a chair, flat screen monitor, wireless
       headset, etc.
      Employee’s emotional and behavioral status (perception of need)
      Any additional information in which the OC-Med Risk Program Coordinator and the Physical
       Therapist should be aware of prior to contacting the employee and conducting the evaluation

Ergonomic Training Presentation for a department or a group of employees:

      Contact person
      Contact person’s e-mail address, phone number and extension
      Department
      Location of the training
      What kind of training is needed/requested
      Time frame for scheduling
      How many employees will be in attendance
      Any particular ergonomic issues or problems which need to be addressed during the training
       program


August 2012 ed.             VCSSFA Workers’ Compensation Guidelines                            Page 39
ERGONOMICS ASSESSMENT
                                                                        Prevention         Early Intervention          Post Injury

Name:                                          Job Title:                            Dept #:                                         Date of Evaluation:
                                                                                     Phone #:
Sex:        M   F          Height:                                                   Email #:
Dominant Hand:             Right       Left    Corrective Lenses?       Yes No       Supervisor:                                     Date of Hire:
                                               Type: Contacts Bifocals               Supervisor’s email:
Work hours/schedule:                           Overtime:        Yes      No          Lunch/Breaks:          Yes        No
Commute time to work:                          Hours:                                Frequency:


Job Duties:




                                     Please provide some information regarding the frequency of your work tasks using the following (please circle):
                                                                Never                Rarely                 Occasional                    Frequently               Constantly
                                                                              (0 - 10% of the shift)   (up to 33% of the shift)      (34 - 66% of the shift)   (67 – 100% of the shift)
       1.   Computer use:                                         N                    R                          O                             F                          C
       2.   Numeric keypad use:                                   N                    R                          O                             F                          C
       3.   Inputting info. from documents:                       N                    R                          O                             F                          C
       4.   Telephone use:                                        N                    R                          O                             F                          C
       5.   Handwriting:                                    N     R                    O                          F                             C
How often are you sitting?                                        N                    R                          O                             F                          C


                                                 Please provide information regarding any current physical discomfort levels (optional):
                                                                Never                Rarely                 Occasional                    Frequently               Constantly
                                                                              (0 - 10% of the shift)   (up to 33% of the shift)      (34 - 66% of the shift)   (67 – 100% of the shift)
       1.   Hand/wrist discomfort:                                N                    R                          O                             F                          C

 August 2012 ed.
                                      VCSSFA Workers’ Compensation Guidelines                                         Page 40
    2.   Shoulder/arm discomfort:                          N                   R                        O                   F           C
    3.   Neck discomfort:                                  N                   R                        O                   F           C
    4.   Back discomfort:                                  N                   R                        O                   F           C
    5.   Hip/leg discomfort:                       N       R                   O                        F                   C



Please elaborate on areas of discomfort noted above:
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
Please describe any non-functioning equipment (i.e. chair broken, keyboard tray not working, mouse sticks):
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
What do you like/dislike about your workstation?
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
Off-Work Activities:

    Hobbies/Recreation:                     _______________________________________________________________________________________

    Computer use at home:                   _______________________________________________________________________________________




                                                                Identify equipment currently used:
______________________________________________________________________________________________________________________



Training Section:
    The employee was instructed in how to adjust the chair:                                                           Yes   No    N/A
    The employee was instructed in how to adjust the keyboard platform:                                               Yes   No    N/A
    The employee was instructed in work pacing and rest pause techniques:                                             Yes   No    N/A
    The employee has completed ergonomics training (classroom or online):                                             Yes   No    N/A
 August 2012 ed.                VCSSFA Workers’ Compensation Guidelines                                     Page 41
                                                                  RISK FACTOR ASSESSMENT:
     Risk Factor        Affected Areas          Problems/Issues              Recommendations                 Equipment            Implementation
Awkward Postures




Repetition



Contact Stress


Environment




   Number of Risk Factors       Before evaluation:        After on-site adjustments:    After install of equipt:   At time of follow-up evaluation:




 August 2012 ed.            VCSSFA Workers’ Compensation Guidelines                            Page 42
                                                            Appendix H




                            WellComp MPN
                  Informational Pamphlet




August 2012 ed.
                  VCSSFA Workers’ Compensation Guidelines       Page 43
August 2012 ed.
                  VCSSFA Workers’ Compensation Guidelines   Page 44
August 2012 ed.   VCSSFA Workers’ Compensation Guidelines   Page 45

				
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