The United States Department of Labor (U.S. DOL) of Office Workers' Compensation Programs (OWCP) that provides wage replacement benefits, medical treatment. vocational rehabilitation. and other benefits to federal and state workers (or eligible dependents) who are injured at work or who acquire an occupational disease. Accident is described as an unplanned or unexpected happening causing injury or death not due to any fault of the employee.
2 Programs of Workers' Compensation:
1 Federal Workers' Compensation Programs
1. Federal Black Lung Program - A program that provides benefits to coal miners.
Pneumoconioses and Other Lung Diseases Due to External Agents
Definition: Permanent deposits of particulate matter, within lungs, due to occupational or
environmental exposure, results in chronic induration and fibrosis (see specific
listing in ICD-9 500-508 code range while in ICD-10 J60-J70)
Sample Codes: ICD-9 ICD-10 Description
500 J60 coal workers' pneumoconiosis
501 J61 asbestosis
2. Longshore and Harbor Workers' Compensation Act - A program that provides benefits for private and public employees who work on the sea nationwide. Marine time workers and Workers extracting natural resources.
3. Federal Employees Compensation Act (FECA) - covers 2 classification of injury:Traumatic injury and occupational illnesses.
Traumatic injury - an injury cause y specific event during a single work day. Falling off the
ladder and breaking an arm (fractured arm) is an example of traumatic
injury.
Occupational Illness - a condition caused by a continued exposure to the workplace.
Respiratory trouble due to dust inhaled for years in a mine is considered an
occupational illness.
4. Energy Employees Occupational Illness Compensation Program (EEOICP) - In 2001, started providing benefits to eligible employees an former employees of the Department of Energy, its contractor and subcontractors or to certain survivors of such individuals and certain beneficiaries of Radiation Exposure Compensation Act. The OWCP is responsible for adjudicating and administering claim filed by employees, former employees or certain qualified survivor.
2. State Workers' Compensation Programs has 4 Types of Coverage
1. State Compensation Fund - Employer pay a premium to the state, the states then ensures the employees who are covered by the plan, and pays benefits based on the law established y the state.
2. Employer Self-Insured Programs - Employer with sufficient capital are allowed to set up a fund to cover expenses incurred by job related accident or illnesses. State regulations require a percentage of capital e set aside for the fund.
3. Private Commercial Compensation Programs- In this case a private health insurance program meeting state determined guidelines provides the workers' compensation coverage.
4. Combination Programs - In some states employers are allowed to have a combination of state funded, private or self-insured plans. These plans are put together in package to the est suit the needs of the business and their employees.
To be eligible for workers' compensation, employees must be injured while working within the scope of their job description, be injured while performing service required by the employer or contract an illness that can be directly linked to employment.
Classification of workers' compensation cases are as follows:
a. medical claims with no disability - work-related injury that are easily treated and employee is expected to return to work in a short duration of time.
b. temporary disability - claims that include employee that is expected to unable to work for a period of time while they are recovering from their injuries. Coverage includes lost wages and medical services. The employee is expected to return to work but they may not able to hold their previous position.
c. permanent disability - work-related injury that involves permanent disability of the employee. The level of the employees' impairment is determined y the physician once a patient has reached the limitation on their ability to recover. It ranges from partial or full disability. The provider will assign a percentage from 1% to 100%, 100% meaning the employee will no longer be able to work. Benefits include medical care services and wage replacement.
d. vocational rehabilitation - claims that cover vocational retraining expenses for both temporary and permanent disability cases Vocational rehabilitation retains an injured employee so he or she can return to workforce. Watch the sample video below:
Providers are required to accept workers' compensation reimbursement as payment
in full.
Balance billing of patients is prohibited. Many workers compensation programs
incorporate managed care to improve the quality of medical benefits and services provided,
as well as to control costs.
Forms used in processing reimbursement of services:
1. First Report of Injury form
Completed when the patient first seeks treatment for work-related injury or illness. '
The report is filed in quadruplicate with a copy distributed to the following:
1.1 State Workers' Compensation Board or Commission
1.2 Employer-designated compensation insurance
1.3 Injured patient's employer
1.4 Patient's work-related injury chart separate from personal medical record.
A detailed narrative progress/supplemental report must filed to document any significant change in the medical or disability status. The completion of the information falls on the shoulder of the physician. However, the insurance specialist will need to gather the information required for reporting. This report contains:
2.1 Patient name & WorkComp number
2.2 Treatment & Progress report
2.3 Work Status at present time
2.4 Statement of further treatment needed
2.5 Estimate the future status regarding work or permanent loss or disability
2.6 Copies of X-ray, lab results, or consultation reports if any
The physician must sign the original form and all photocopies of these reports. Patient signature is not required on the form for releasing report to compensation payer or commission/ board. Must be in duplicate copy because:
One copy is sent to the compensation payer
One copy is retained in the patient's file
An acknowledgement receipt of claim will be generated by the payer, commission/board. The acknowledgment will contain file or case number assigned to the claim. The claim number should be written on all further correspondence forwarded to the employer and payer.
3. CMS-1500 - (v02/12)
In order to file workcomp claim, you need to fill out CMS-1500 claim form. This form is filed with the Office of Workers' Compensation Programs (OWCP), a part of the U.S. Department of Labor.
To ensure filing to State Workers' Compensation claims corectly, always contact the state workers' compensation office, board or commission and ask these important questions:
1. What forms and records are needed from the medical office and where can these be obtained?
The claim forms and medical records that physicians are required to provide vary from state to
state to state.
2. What organizations and agencies should receive the claim forms?
Always verify the correct address where to send the claim.
3. What is the filing deadline?
Remember, failure to file within required deadline may result in denied claim or reduced
payments.
4. How is reimbursement is determined?
Does the state workers' compensation program use a system of allowable charges or fee
schedule with set fees for each medical service?
5. Can the patient or employer be billed for the costs of medical services and treatments that the state workers' compensation does not cover?
By law some states prohibit physicians from billing patients for any unpaid balances on workers' compensation cases.
Additional Forms that should be kept on office files:
1. Employer Report of Occupational Injury or Illness
Forms that an employer need to keep on their office files:
1. OSHA Form No.300 Log of Work-Related Injuries and Illnesses - Employers must keep records of their employee's work-related injuries and illnesses. This form is obtained from OSHA office or from any US Department of Labor. This document must be on file at the workplace and available to employees and OSHA compliance officers on request. This form must be retained in 5 years.
2. Cal/OSHA Form 301 Injury and Illness Incident Report - This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable workrelated injury or illness has occurred. Together with accompanying Annual Summary, these forms help the employer and Cal/OSHA develop a picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers’ compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the instructions and information asked for on this form. According to CCR Title 8 Section 14300.33 Cal/OSHA’s recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains. If you need additional copies of this form, you may photocopy and use as many as you need.
Who pays workers' compensation for the injured patient?
The employer pays all the premium. Patient are not paying any deductible and no copayments either.
Who reimburses the physician for services provided to injured patient?
The State Compensation Board or Commission establishes a schedule of approved fees. Many states use the Relative Value Study unit-value scale; others have implemented managed care. All providers must accept the compensation payment as payment in full.
Example: CPT code 99204 is assigned a fee of $28.00 and RVS is 2.3, the reimbursement is $64.40.
Formula: 28 x 2.3 = 64.40
Internet Resources:
California Department of Industrial Relations
Office of Workers' Compensation Program includes U.S Department of Labor
