a) Before Workers’ Compensation the employer was responsible for an injury/death
or illness due to his/her employees.
b) Number of accidents increased into 19th century and legal processes were
uncertain, therefore, legal provisions were required.
c) Use to be “workmen” but later changed to “workers” to avoid sexual bias.
a) Federal laws-miners, maritime workers and those who work for the government
b) State laws-employers and employees within each state, but laws vary by state
a) Provide best medical care, ensure prompt return and maximum recovery
b) Provide income to employee and their dependents
c) Reduce court delays, costs, and workloads
d) Relieve public and private charities of financial drains
e) Eliminate payment of fees to attorneys and witnesses, and time consuming trials
f) Encourage employer interest in safety and rehabilitation
g) Promote study of causes of accidents and reduce preventable accidents and human
a) Those entitled include: private business employees, state employees and federal
b) Accident- unplanned and unexpected happening traceable to a definite time and
place causing injury-damage or loss
c) Occupational illness or disease-any abnormal condition or disorder caused by
exposure to environmental factors associated with employment, including acute
and chronic illnesses or diseases that may be caused by inhalation, absorption,
ingestion, or direct contact.
a) Federal Laws-
b) Workmen’s Compensation Law of the District of Columbia.
c) Federal Coal Mine Health and Safety Act
d) Federal Employees Compensation Act (FECA)
e) Longshoremen’s and Harbor Workers’ Compensation Act (LHWCA)
f) State Laws-
g) Compulsory-Each employer required to accept its provisions and provide specific
h) Elective-The employer may accept or reject the law. Coverage is only elective in
two states New Jersey and Texas
i) Minors(under age of 18) are covered by workers’ compensation\
j) Interstate Laws-When billing, follow the rules and fee schedule of the state in
which the workers’ compensation claim was originally filed
k) Volunteer workers-some states have laws to compensate civil defense and other
volunteer workers, such as firefighters who are injured in the line of duty
l) Funding-Employers may qualify as self-insurers in 48 states and territories. A
number of states permit employers to purchase insurance from either a
competitive state fund or a private insurance company
m) The employer pays the premiums for workers’ compensation insurance, the
amount depends on the employee’s job and the risk involved in job performance
n) Second-Injury Fund- established to meet problems arising when an employee has
a preexisting injury or condition and is subsequently injured at work. The
preexisting injury combines with the second injury to produce a disability that is
greater than that caused by the latter alone. The functions of the fund are to
encourage hiring of the physically handicapped, allocate more funds to providing
benefits to such employees
o) Minimum number of employees-each state requires a minimum number of
employees in a business before the state workers’ compensation law comes into
effect. California has a minimum of 1 employee required.
p) Waiting periods-each state has its own laws regarding the time period that must
elapse before income benefits are payable. This affects only wage compensation
because medical and hospital care are provided immediately. California has a
waiting period of 3 days.
6. Benefits of State Compensation
a) Medical treatment
b) Temporary disability indemnity
c) Permanent disability indemnity
d) Death benefits for survivors
e) Rehabilitation benefits
7. Types of State Claims
a) Nondisability Claim-minor injury in which patient is seen by physician but is
able to continue working
b) Temporary Disability Claim-worker has a work related injury or illness and is
unable to perform the duties of his or her occupation for a specific time or range
c) Insurance adjuster- person who at the workers’ compensation insurance carrier
who oversees the industrial case. Evaluates injury or illness and predicts in
advance the amount of money reserves needed to cover medical expenses and
calculate as accurate a reserve as possible for the weekly TD payments to the
injured. Which are usually based on the workers’ earnings at the time of injury.
d) Vocational rehabilitation-most states provide rehabilitation in the form of
retraining, education, job guidance, and placement.
e) Work Hardening-individualized program using simulated or real work tasks to
build up strength and improve the workers’ endurance toward a full days work.
CPT codes 97545 and 97546 are used to report work hardening.
f) Ergonomics-evaluation of the work site is performed and modifications may be
instituted to the job or work site to lessen the possibility of future injury and to get
the employee back to gainful employment.
8. Permanent Disability Claim
a) The patient or injured party is usually on TD benefits for a time and then
concludes that he or she is unable to return to his or her former occupation. This
can happen with the loss of hand, leg eye or some neurological damage.
b) Final report must include the words “permanent and stationary”
c) This means the patient has recovered to the fullest extent possible, the physician is
unable to do anything more for the patient, and the patient will be hampered by
the disability to some extent for the rest of his/her life.
d) This type of examination (P&S) is usually comprehensive and a level 5 in the
e) The case is then rated for PD and a settlement called a Compromise and Release
(C&R) is made for the total sum. The case can then be closed.
f) Reasons that delay closing of the case include: unanswered questions, vague
terminology used by the physician, omitted signatures on forms or written reports,
incorrect billing or inadequate progress reports.
g) Rating-final determination of the issues involving settlement of an industrial
accident is known as adjudication or the rating of a case.
h) If an injured person is dissatisfied with the rating after the case has been declared
P&S, he or she may appeal the case by petition to the Workers’ Compensation
i) Sub rosa films-Videotapes are made over 2-3 days without the patient’s
9. Fraud and Abuse
a) Increases in fraudulent claims were seen in the 1990s.
b) Physicians responsible for determining the legitimacy of work injuries and
reporting the findings accurately.
c) Individuals who work with workers’ compensation cases should notify the
insurance carrier of any suspicious situation.
10. Occupational Safety and Health Administration Act of 1970 (OSHA)
a) Established by Congress to protect employees against on-the-job health and safety
hazards. This program includes strict health and safety standards and a complaint
b) OSHA has regulations for filing complaints, inspections, record keeping and
reporting. See current guidelines for information.
11. Legal Situations
a) Physicians who conduct medico legal evaluations of injured workers must pass a
complex medical examination. They are then certified by the Industrial Medical
b) Deposition-proceeding in which an attorney asks a witness questions about a case,
and the witness answers under oath but not in an open court.
c) Lien-(liable) the right of a lien expresses legal claim on the property of another
for the payment of a debt. May be called an encumbrance.
12. Directional Terms
a) commonly used on workers’ compensation reports
13. Reporting Requirements
a) The laws clearly state that the injured person must promptly report the industrial
injury or illness to his or her employer or immediate supervisor, which may be a
safety officer in some businesses.
b) The first report of an industrial injury submitted by the employer and the
physician is required by law in most states. The employer sends an Employer’s
Report of Occupational Injury or Illness Form to the insurance company. Time
limits vary from state to state.
c) In addition to the employer’s report, the employer may complete and sign a
medical service order, giving this to the injured employee to take to the
physician’s office. This authorizes the physician to treat the injured employee.
d) The form should be photocopied and the copy retained for the physician’s files.
The original should be attached to the Doctor’s First Report of Occupational
Injury or Illness (preliminary report). This report can also be done on the
physician’s own letterhead, service order or billhead. This is submitted after the
injured person is seen.
e) Progress or Supplemental Reports are sent to the insurance carrier after 2 to 4
weeks of treatment to give information on the current status of the patient.
f) A final report is sent to the insurance carrier when the physician feels that the
patient is able to return to work. When the patient returns to work the insurance
carrier then closes the case.
g) If the injured person continues to need treatment subsequent progress reports will
continue to be sent to the insurance carrier as needed.
14. Financial Responsibility
a) The contract for treatment in a personal illness or injury case is between the
physician and the patient, who is responsible for the entire bill. However, when a
business is self-insured, a person is under a state program for care, or an
individual is being treated as a workers’ compensation case, the financial
responsibility exists between the physician and the insurance company or state
program. As long as treatment is authorized by the insurance carrier then they are
responsible for payment.
b) A physician who agrees to treat a workers’ compensation case must agree to
accept payment in full according to the workers’ compensation fee schedule.