Workers' Compensation 1

Workers' Compensation Claims Process

Ashshanti Bryant

HCR/230

July 25, 2010

M. LaShay Martin MBA/HCM

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Workers' Compensation Claims Process

When an on-the-job injury occurs the incident should be reported to the employer in a

timely manner and statements should be in writing. When notification is delivered tot the

state the employer must inform the insurance carrier and the state workers' compensation

office as well. In most instances, the physician who treats the employee is provided a medical

service order. Generally, the employer or insurance company chooses the facility or

physician the employee uses. Most managed care companies have contracts with employers

for services. Because of these contracts, the employee must be examined and treated by a

physician within the managed care plan's network. If the employee refuses to agree with the

demand, services may not be allowed (Bayes, Newby, Seggern, & Valerius, 2008).

According to the severity of the injury, the company physician or physician of record is

the first to treat the ill or injured employee. Significant changes in an employee's condition,

which affects the employees ability to perform effectively at his or her workplace is

monitored and recorded by the physician of record. The return-to-work date, the

management of the employees disability, and the decision of the severity of the injury is the

responsibility of the physician of record. In addition, a report with the insurance status will

be filed by the physician of record or filed when mandatory by state rules and regulations.

Costs are conferred to the workers' compensation insurance carrier and is immediately

reconciled by the carrier. Established fee schedules limit rates. Rates are limited to an

established fee schedule and medical costs may not be passed onto employees. Likewise, any

charges or fees greater than the established fee for the service provided may not be charged

to the employer (Bayes, Newby, Seggern, & Valerius 2008).

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Depending on the state, generally between 24 hours to 10 days of when the injury or

illness occurs; the injury form must be filed promptly by the employer or the treating

physician under state law. Documents may be certified electronically, sent to the carrier, or

recorded, depending on the insurance carrier. In this process a claim number is issued and is

used to determine the validation of the claim as well as the eligibility for workers

compensation with notification sent directly to the employer. Notification that concludes to

either the admission the employer is responsible for treatment of the injuries sustained at the

workplace, which is called an Admission of Liability or a rejection of liability which known

as a Notice of Contest (Bayes, Newby, Seggern, &Valerius 2008).

In the process of workers' compensation claims, each individual in the workplace has a

responsibility. An employee's responsibility consist of reporting work-related injuries or

illnesses immediately to the supervisor, regardless if the worker plans to claim workers'

compensation or not. A licensed medical practitioner should supply the employee with a

Workers' Compensation Medical Certificate. Employee must complete a Worker’s Claim for

Compensation form and give it to his or her employer along with the Workers' Compensation

Medical Certificate. A grace period of six months is the time all petitions should be filed

from the date of injury. In the event of an extended absence from work, a new Workers'

Compensation Medical Certificate is given to the employer in advance or immediately after

his or her previous Certificate expires. Benefit payments are determined by this process. The

employee must participate in rehabilitation efforts or placement in alternative positions. The

amount of benefits received is based on the employees assistance. Employees should be

readily available for medical examination by the physician chosen by the employer at any

given time or location as well as receive and comply with medical advice. Failure to follow
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the implied rules may result in the disruption of weekly benefit payments until the issue is

resolved by the Workers Rehabilitation and Compensation Tribunal. One exception is the

rejection of surgery by the employee; this will result in weekly benefit payments to continue

until the Workers Rehabilitation and Compensation Tribunal comes to a decision. Last, he or

she must obtain a release certificate from his or her medical practitioner before returning to

work (Injury Reporting and Claims Process., 2008)

The employer is responsible for filing injury reports on behalf of the injured employee

provided the physician has not done so. The employer is also responsible for distributing

benefits by checks without taxes withheld.

Physicians are responsible for the treatment of patients, the determination of the extent of

injury, the decision of disability and specifying a return to work date. In the event of any

substantial changes in the employees condition, the physician must present a progress report

to the insurance carrier if the change affects the disability as well as submit a claim to the

insurance carrier for payment.

The responsibility of the insurance carrier is to pay for services rendered by physicians or

heath care facilities on behalf of the patient and to notify the employer the eligibility of the

employee for workers compensation benefits.

HIPPA Privacy Rules apply to Workers' Compensation differently toward the

traditional patient health care privacy. In most instances a workers' compensation case health

care provider can disclose a patient’s protected health information or PHI without the

patient’s permission or knowledge to his or her employer. In addition, HIPPA Privacy Rules
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allow disclosure of PHI information for workers' compensation purposes without the patients

knowledge, or permission as well. Unfortunately, workers' compensation claim information

is not protected under the same privacy regulations as other medical information. Virtually

all states allow employer and claims adjusters unrestricted access to the workers'

compensation records. The Disclosure of information needed for any legal or governmental

issues in reply to a subpoena or court order, is also permitted, and will be granted upon

request. "Following the minimum necessary standard, covered entities can reveal facts to the

full degree permitted by state or other law" (Valerius, Bayes, Newby & Seggern, 2008).

Under the Privacy Rule individuals has no right to demand a physician to withhold the

disclosure of their PHI for workers' compensation purposes if the requested information is

allowed by law. Nevertheless, the release of an employee's information to an employer or

insurance agency that does not pertain to the workers' compensation claim requires written

approval. (Bayes, Newby, Seggern, &Valerius, 2008).

Last, there are implications of restricted access to a patient's medical records.

As expected the law has provided the federal government no restriction when viewing a

patient's medical record without his or her consent. Under this statute government officials

and law enforcement have access to medical records without consent as well. Accessing an

individual's medical information without consent is a violation of his or her Fourth

Amendment rights. However, the Fourth Amendment clearly allows investigations to be

conducted without an official warrant in emergency situations only (Paul, 2004, p. 2).

Furthermore, if needed law enforcement has the capability to obtain a warrant prior to an

investigation; afterwards the medical records would be disposed of (Paul, 2004, p. 2).
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In conclusion, the workers' compensation claims process consist of rules and

regulations that must be adhered by the employee, employer, insurance carrier and the

treating physician.

References

Injury Reporting and Claims Process (2008). Roles and responsibilities. Retrieved July 24,

2010 from http://www.tenders.tas.gov.au/

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Paul, R. (2004). A Free-Market Approach to Medical Privacy 18 Journal of American

Physicians and Surgeons Volume 9 Number 1 Spring 2004 Page 2. The Roots

of the Current Crisis, 9(1), 2. Retrieved July 24, 2010 from

http://www.jpands.org/vol9no1/paul.pdf.

Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated

claims process approach (3rd ed.). Boston: McGraw-Hill