Understanding Work Related Injuries HCR230 Understanding Work Related Injuries Claims Process When an injury occurs on the job, it must be reported verbally and in writing to the employer within a certain time period. Once notified the employer must notify the state workers’ compensation office and insurance carrier, within a certain time period. In some cases the employee is given a medical service order to take to the physician for treatment (Valerius, Bayes, Newby, & Seggern, 2008). Responsibility of Physician of Record
Responsibility of the treating physician or physician of record is to treat the injured or ill employee. This physician treats the patient’s condition and evaluates the percentage of disability and the return-to-work date. The physician of record files a progress report with the insurance carrier each time there is a substantial change in the patient’s condition that affects their disability status or when the state requires (Valerius, Bayes, Newby, & Seggern, 2008). Responsibility of Employer and Insurance Carrier
Providers submit their charges to the workers’ compensation insurance carrier and are paid directly by the carrier. Charges are limited to an established fee schedule. Patients cannot be billed for any medical expenses. The employer may not be billed for any amount that exceeds the established fee (Valerius, Bayes, Newby, & Seggern, 2008). The employer or physician of record is responsible for the First Report of Injury form within a certain time period. The amount of time varies with each state, but ranges from twenty-four hours to ten days.
The form contains information about the patient, the employer, the injury or illness. This report can be filed electronically or mailed (Valerius, Bayes, Newby, & Seggern, 2008). According to the website (Idaho State Insurance Fund, 2012) when an injury occurs in the State of Idaho, the employer should immediately provide prompt medical attention, transport the injured worker to medical facility, show concern for the injured worker, conduct an investigation, document all details, obtain written statements from injured worker and witness, notify
State Insurance Fund immediately if the injury is severe, and complete the First Report of Injury. In Idaho the claims examiner is the primary contact for coordinating all actions relating to medical treatment and finalizing of the claim (Idaho State Insurance Fund, 2012). Responsibility of Employee in the State of Idaho
According to the website (Idaho State Insurance Fund, 2012) in the State of Idaho, the injured worker can make the claims process run along promptly by notifying their supervisor immediately, help fill out the First Report of Injury or Illness form completely, make sure their name appears exactly like it does on the company payroll, seek medical attention immediately and ask that all documents are sent to the State Insurance Fund, have their claim number when making any phone calls or returning all documents, attend all scheduled medical appointments, avoid activities that would slow or stop recovery process, cooperate with the Industrial Commission Rehabilitation Division, keep their employer informed of your progress and when they are able to return to work, and inform the State Insurance Fund about changes in their employment status while their claim is open. The insurance carrier assigns a claim number to the case, determines if the claim is eligible for workers’ compensation and notifies the employer. This determination is either an Admission of Liability stating the employer is responsible or a Notice of Contest which is a denial of employer liability. The worker must be notified of the determination within the allowed time (Valerius, Bayes, Newby, & Seggern, 2008).
If the employee is eligible for compensation for lost wages, checks are sent directly to the employee with no taxes deducted. If the claim is denied the employee must pay back all the medical bills associated with the accident. These charges may be submitted to the individuals’ own health insurance carrier for payment (Valerius, Bayes, Newby, & Seggern, 2008). Appeals Employees may appeal workers’ compensation decisions. The first step to appeal is to request mediation. A mediator is an impartial individual who works with both parties to obtain a satisfactory outcome. If mediation fails for the employee, there can be a formal legal hearing requested and a judge will hear both sides of the claim and make a decision.
If the decision is still not satisfactory then the employee may appeal to a higher court, such as a workers’ compensation appeals board or a state supreme court (Valerius, Bayes, Newby, & Seggern, 2008). Workers’ Compensation and the HIPAA Privacy Rule A workers’ compensation case is one of the few situations where a physician can disclose a patient’s health information (PHI) to an employer without the patient’s releasing authorization. Workers’ compensation cases are not subject to the same confidentiality rules as medical records. Some states and federal law allow claims adjusters and employers unrestricted access to workers’ compensation files.
A patient does not have the right under the Privacy Rule to request a physician restrict or not disclose their PHI for workers’ compensation purposes when that disclosure is require by law. But the physician does not have the right to disclose any previous condition of the patient that is not directly related to the claim of an employer or insurer, that would require written authorization of the patient (Valerius, Bayes, Newby, & Seggern, 2008). References Idaho State Insurance Fund. (2012). Retrieved from http://www. idahosif. org, November 3, 2012. Valerius, J. , Bayes, N. , Newby, C. , & Seggern, J. (2008). Medical Insurance: An integrated claims process approach (3rd ed. ). Boston, MA: McGraw-Hill.