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Workers' Compensation Claims Process Ashshanti Bryant HCR/230 July 25, 2010 M. LaShay Martin MBA/HCM
Costs are conferred to the workers' compensation insurance carrier and is immediately reconciled by the carrier. & Valerius. Generally. In addition. any charges or fees greater than the established fee for the service provided may not be charged to the employer (Bayes. a report with the insurance status will be filed by the physician of record or filed when mandatory by state rules and regulations. & Valerius 2008). Rates are limited to an established fee schedule and medical costs may not be passed onto employees. 2008). the physician who treats the employee is provided a medical service order.Workers' Compensation 2 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. 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. and the decision of the severity of the injury is the responsibility of the physician of record. services may not be allowed (Bayes. Seggern. Because of these contracts. The return-to-work date. Established fee schedules limit rates. According to the severity of the injury. When notification is delivered tot the state the employer must inform the insurance carrier and the state workers' compensation office as well. the company physician or physician of record is the first to treat the ill or injured employee. Seggern. the employer or insurance company chooses the facility or physician the employee uses. the employee must be examined and treated by a physician within the managed care plan's network. In most instances. Newby. Most managed care companies have contracts with employers for services. Likewise. the management of the employees disability. Newby. If the employee refuses to agree with the demand. .
the injury form must be filed promptly by the employer or the treating physician under state law. generally between 24 hours to 10 days of when the injury or illness occurs. Notification that concludes to either the admission the employer is responsible for treatment of the injuries sustained at the workplace. sent to the carrier. or recorded. Documents may be certified electronically. Failure to follow . regardless if the worker plans to claim workers' compensation or not. Seggern. a new Workers' Compensation Medical Certificate is given to the employer in advance or immediately after his or her previous Certificate expires. &Valerius 2008). The employee must participate in rehabilitation efforts or placement in alternative positions. 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. In the process of workers' compensation claims. depending on the insurance carrier. A grace period of six months is the time all petitions should be filed from the date of injury. Newby. Benefit payments are determined by this process. An employee's responsibility consist of reporting work-related injuries or illnesses immediately to the supervisor. 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. A licensed medical practitioner should supply the employee with a Workers' Compensation Medical Certificate. The amount of benefits received is based on the employees assistance. each individual in the workplace has a responsibility. which is called an Admission of Liability or a rejection of liability which known as a Notice of Contest (Bayes.Workers' Compensation 3 Depending on the state. 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. In the event of an extended absence from work.
In the event of any substantial changes in the employees condition. the decision of disability and specifying a return to work date.. In addition. 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.Workers' Compensation 4 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. HIPPA Privacy Rules apply to Workers' Compensation differently toward the traditional patient health care privacy. Physicians are responsible for the treatment of patients. Last. this will result in weekly benefit payments to continue until the Workers Rehabilitation and Compensation Tribunal comes to a decision. 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. he or she must obtain a release certificate from his or her medical practitioner before returning to work (Injury Reporting and Claims Process. The employer is also responsible for distributing benefits by checks without taxes withheld. the determination of the extent of injury. 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. 2008) The employer is responsible for filing injury reports on behalf of the injured employee provided the physician has not done so. HIPPA Privacy Rules .
2008). Last. Nevertheless. 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. workers' compensation claim information is not protected under the same privacy regulations as other medical information. Under this statute government officials and law enforcement have access to medical records without consent as well. p. 2008). covered entities can reveal facts to the full degree permitted by state or other law" (Valerius. 2). "Following the minimum necessary standard. there are implications of restricted access to a patient's medical records. or permission as well. 2004. p. As expected the law has provided the federal government no restriction when viewing a patient's medical record without his or her consent. However.Workers' Compensation 5 allow disclosure of PHI information for workers' compensation purposes without the patients knowledge. if needed law enforcement has the capability to obtain a warrant prior to an investigation. &Valerius. Accessing an individual's medical information without consent is a violation of his or her Fourth Amendment rights. (Bayes. Bayes. the Fourth Amendment clearly allows investigations to be conducted without an official warrant in emergency situations only (Paul. is also permitted. The Disclosure of information needed for any legal or governmental issues in reply to a subpoena or court order. Newby. Newby & Seggern. . Unfortunately. Virtually all states allow employer and claims adjusters unrestricted access to the workers' compensation records. Furthermore. and will be granted upon request. 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. 2004. Seggern. 2). afterwards the medical records would be disposed of (Paul.
gov.au/ . References Injury Reporting and Claims Process (2008).Workers' Compensation 6 In conclusion. insurance carrier and the treating physician. 2010 from http://www.tas. Retrieved July 24. the workers' compensation claims process consist of rules and regulations that must be adhered by the employee.tenders. employer. Roles and responsibilities.
. The Roots of the Current Crisis. Medical insurance: An integrated claims process approach (3rd ed. (2004).. J. Bayes.pdf. Boston: McGraw-Hill . R.. C. 2. & Seggern. Newby. J.Workers' Compensation 7 Paul. Valerius. 9(1). A Free-Market Approach to Medical Privacy 18 Journal of American Physicians and Surgeons Volume 9 Number 1 Spring 2004 Page 2. N.).org/vol9no1/paul. Retrieved July 24. 2010 from http://www.jpands. (2008).
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