...1. How do employer priorities affect claim adjudication and management in workers’ compensation systems? The number one priority for all companies is to be successful and that means being profitable. As the global market becomes more competitive, many businesses must cut costs and adopt strategies to ensure that their doors remain open. When an employee injures themselves on the job the potential costs of an injury claim can significantly impact the WCB premiums for a company (Barnetson, 2010). Workers’ Compensation Boards use its experience rating system to adjust an employer’s premiums based on its injury prevention performance compared to the industry average. Performance compared to that average determines if employers are awarded a rebate or presented with a surcharge (Barnetson, 2010). The system is designed to provide an incentive to employers in hopes they will improve safety performance and prevent injuries, but it also can create pressure to minimize claim costs (Barnetson, 2010). Instead of making safety improvements to the operation, employers may attempt to game the system through the adoption of aggressive claim management and adjudication strategies (Barnetson, 2010). These strategies are designed to do three things; get workers back to work as soon as possible; dispute and appeal claims where feasible; and lower premium rates without having to make significant changes to work processes. More and more employers are recognizing that an early return to work...
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...Worker's Compensation Claims Process “In order for an injury to be covered under a workers’ compensation plan it must be in result in personal injury or death, occur by accident, arise out of employment, and/or occur during the course of employment. Workers’ compensation insurance pays an employee’s medical bills that result from a job-related injury; disability compensation programs do not pay medical expenses. Workers’ compensation insurance provides coverage for illnesses and injuries that are job-related. Most disability compensation programs provide benefits for injuries or illnesses that are not work-related.” (Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.). Boston, MA: McGraw-Hill) “The physician who treats the injured or ill employee is known as the physician of record.” (Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.). Boston, MA: McGraw-Hill) The physician’s responsibility is to determine the patient’s condition, percentage of his/her disability, and when he/she is able to return to work. The physician will file a progress report with the insurance carrier showing changes of the patient’s (employee) condition which may affect his/her disability status. It is the responsibility of either the employer or physician to file the first report of injury within a period of time, this time varies from state to...
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...Worker’s Compensation Claims Process January 21, 2012 HCR/230 Worker’s Compensation Claims Processing is necessary in order to cover an injured worker as timely as possible, and when done properly can have a significant effect on a company and the injured worker who filed a claim. The Worker’s Compensation claims process has several parts. The very first step of the claim process is reporting the worker’s incident to the employer and insurance carrier. This task must be done in a timely manner and should be in writing. There is a deadline for making a claim on an injury and it may vary from state to state. The next step in the claim process is the initial medical exam. The injured employee is sent to a physician. Usually, the physician is of the employer’s or insurance carrier’s choice, but there is an exception. The exception is an employee who specifically states in writing to the employer, that he or she wants their primary doctor to treat them for any injuries. The physician who first attends to the injured worker is now the “physician of record” and must be sure to properly collect and record certain information that will be needed for the worker’s claim. The physician of record is not only responsible for treating the worker’s injury, but also responsible for determining the percentage of disability and the return to work date (if applicable). Progress reports by the physician/provider to the...
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...Injuries HCR 230 ShaNedra Beasley When you are filing a workers' compensation claim there is a process that it must go through. According to Medical Insurance: Workers' Compensation and Disability, when an employee is injured on the job, the injury must be reported to the employer within a certain time period. Most states require notification in writing. Once notified, the employer must notify the State Workers' Compensation Office and the insurance carrier, also within a certain period of time (pg 408 Valerius, Bayes, Newby, Blockwiak). Employers pay for the insurance which supplies medical care coverage and cash compensation to those injured and unable to perform the job task due to a work related injury. With the workers' compensation laws all workers are covered and each individual that is connected has their own liability to guarantee the progression functions effortlessly and also proficiently. Responsibilities of the employers The employer is the first to receive the injury report and it has to be completed by the employer or by the physician in a timely manner which is considered under the state law. The time frame to complete a claim form does vary from state to state but it is normally between twenty-four hours up until about ten days. On the claim forms you have to provide the patients general information about them, information about the employer, and the injury to the employer or illness. Claim forms can be filled electronically or mailed directly to the...
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...Reducing Workers Compensation Claims According to an essay published online by CCH Incorporated, the first step in reducing workers’ compensation costs involves ensuring that your company has effective safety and accident prevention programs in place to reduce the amount and severity of workplace illnesses and injuries. In addition to those programs, there are policies and procedures that should be implemented to help supervisors and Human Resources professionals in handling workers’ compensation claims in the most expedient manner possible. Having an active safety program has a number of benefits. Some are obvious. Others are not. A safety program gives employees a sense that their employer cares about them. Issuing personal protective equipment should be part of the safety program as should periodic inspection and replacement of worn or damaged safety equipment. Rotating work schedules or job duties can reduce repetitive-stress injury problems. An additional benefit is that doing so keeps workers more interested in their work and more focused on the job they are doing which also tends to reduce injuries. A mandatory safety training program also lets your employees know that any work related injury is bad for them and bad for the company. All employees should participate in safety activities including those workers in administrative positions or performing office work. Ideally, the message employers want to deliver is that everyone has a vested interest in minimizing these...
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...Related Injuries Workers compensation was developed in the early 1900’s to provide employees who have been injured on the job with compensation for their injuries, and it protects employers from liability for employee’s injuries. The benefit of workers compensation really goes both ways, it not only provides a protection for the employer from lawsuits, but also provides the employee a sort of financial safety net so if they are injured on the job and cannot work they will have a means for supporting their family. If you do find yourself in this situation it helps to know who is responsible for what. If certain steps are not followed you can bet that your claim will be denied. In regards to HIPAA Privacy Rule, workers’ compensation claim information is not subject to the same confidentiality rules as with other medical records. The HIPAA privacy rule permits disclosure of Protected Health Information (PHI) for workers compensation purposes without the patient’s authorization. There is also no restriction on disclosure of any judicial or administrative proceedings in response to a court order, subpoena, or similar process. The information that is provided is what is necessary to file the claim. Individuals may not request a physician to restrict a disclosure of PHI for workers compensation purposes, however, the physician is restricted from disclosure of information about any previous conditions that are not directly related to the claim without the individuals written...
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...Concept of Compensation The literal meaning of compensation is to counter-balance. In the case of human resource management, Compensation is referred to as money and other benefits received by an employee for providing services to his employer. Money and benefit received may be in different forms-base compensation in money form and various benefits, which may be associate with employee, service to the employer receive or benefits, he enjoy lieu of such payment. Cascio has defined compensation as follows: “Compensation includes direct cash payment, indirect payment in the form of employee benefits and incentives to motivate employee to strive higher level of productivity”. Based on above description of compensation, we may identify its various components as follows: 1. Wage and salary. 2. Incentives. 3. Fringe Benefits. 4. Perquisites. COMPENSATION MANAGEMENT: Compensation management, also known as wage and salary administration, remuneration management, or reward management, is concerned with designing and implementing total compensation package. The traditional concept of wage and salary administration emphasized on only determination of wage and salary administration structure in organizational settings. However, over the passage of time, many more forms of compensation, as discussed earlier, entered the business field which necessitate to take wage and salary administration in comprehensive way with suitable change in its nomenclature . Bench has defined...
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...Understanding Work related Injuries Vanessa Cleggs HCR/230 11/17/2013 Myrnell Martin Understanding Work related Injuries In the United States workers who become injured while at work was not able to receive any compensation for their loss of wages or help with medical bills. For a worker to receive any kind of assistance or reimbursement the worker would have to peruse legal action against their employer which could take many years they would also have to prove that the employer was negligent which could also prove too hard to do. By the year 1947 all states had to have workers compensation insurance. Workers compensation is a benefit that is designed to protect injured workers and their employers in case a worker is injured while on the job. The way that it protects the employer is because this insurance is paid into by the employer to pay coverage’s for medical bills and also loss wages this means these payments are not paid directly by the company which helps to protect the company. Protection that is provided through workers compensation for an employee is it will cover any medical cost that the employee may have due to the injury and also while the employee is off working it will provide loss wages payments to the employee. OSHA (Occupational Safety and Health Administration) has set laws and regulations in place to make sure that companies under its jurisdiction provide and safe and healthy place for customers and employees. Companies that are governed under the...
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...involved in an employment task when an accident occurs and requires a claim for work related injury under Workers Compensation Acts. In order to hold an employer accountable for the accident, it will be necessary to show that the employee was engaged in the scope of employment at the time of the accident. Rally’s Auto was running a promotion for free oil changes to boost sales while customers are waiting for their vehicle to be serviced. Exhausted from working overtime for the past week, Jake mistook his thumb as a bolt and injured his thumb. Since Jake was working on a customer’s vehicle, during work hours, and in the company garage it would be considered in his scope of employment. This is assuming there were no drugs or alcohol involved and no horseplay was a cause of the accident. 2. Explain whether or not Herman is responsible for Jake’s injury. Ohio’s workers’ compensation system is a no-fault system. This means that the fault, or negligence of the employee or employer is not an issue in allowance of the claim and the injured employee will be paid compensation and benefits regardless as to any party’s negligence. A few exceptions to the no-fault rule are any injuries resulting from horseplay, self-inflicted injuries, and injuries caused by intoxication of drugs or alcohol is not covered. Rally Auto has more than one employee and is required by law to carry workers compensation insurance. If Rally Auto is required to carry insurance and fails to...
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...things will play out in the court system. This article looks at some of the legal issues raised by the BP oil spill, including legal options for businesses and individuals looking to get back on their financial feet after the oil spill. (For in-depth information on filing a claim with BP's $20 billion compensation fund, see Nolo's article BP Oil Spill: Filing a Claim With BP's Compensation Fund.) The BP Oil Spill: Types of Lawsuits The BP oil spill has already prompted the filing of thousands of lawsuits. Businesses and workers have seen their livelihoods suffer or even disappear in Louisiana, Mississippi, Alabama, Florida, and Texas. Families and individuals in the Gulf region worry about the health hazards posed by the chemicals used to disperse and clean up the oil. And, with its dubious distinction as the largest environmental disaster in U.S. history, the BP oil spill has inflicted immeasurable devastation on the Gulf's coastline, wetlands, wildlife, and ecosystems. Here's a look at the different kinds of lawsuits being filed over the BP oil spill (with links to more information from Nolo where relevant). * Lost business profits and individual income losses. Thousands of businesses and workers in the Gulf region have filed lawsuits against BP, seeking repayment for profits and income that were lost because of the oil spill. These plaintiffs include companies and employees in the commercial...
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...Widget Production Executive Summary Taylor, Inc. requires an analysis of its operations management process to maximize labor productivity. A key component for analysis is a cost-benefit matrix as noted below that outlines current processes compared to the anticipated outcomes for suggested alternatives. | Current | Alternative 1 | Alternative 2 | Wasted motions | 27% | 1% | 7% | Physical lifting | 42 pounds | 12 pounds | 23 pounds | People required | 17 | 6 | 9 | Productivity | 208 units | 392 units | 288 units | Productivity per person | 12.24 units | 65.33 units | 32.00 units | Workers’ compensation claims | 4 | 0.03 | 1.9 | Initial investment | | $1,300,000 | $967,000 | Life of equipment | | 7 years | 5 years | Cost per year | | $185,715 | $193,400 | Wages per year* | $1,520,480 | $536,640 | $804,960 | Cost of workers compensation claims** | $436,000 | $32,700 | $207,100 | Total wages and claims | $1,956,480 | $571,404 | 1,015,156 | Savings from current wages and claims*** | | $1,385,076 | $941,324 | *calculated at $43 per person at 2,080 hours per year **calculated at $109,000 per claim ***calculated by deducting alternative wages and claims from current total of wages and claims Recommended Action – Alternative 1 Alternative 1 appears to provide the best course of action. It reduces the workforce to six persons per eight hour shift yet increases productivity per person to 65.33 units compared with the 12.24 units per person currently...
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...DWC053 Texas Department of Insurance 7551 Metro Center Drive, Suite 100 • MS-94 Austin, TX 78744-1645 (800) 252-7031 phone • (512) 804-4378 fax Division of Workers’ Compensation Complete if known: DWC Claim # Carrier Claim # Employee Request to Change Treating Doctor For use ONLY by Employees NOT in Workers’ Compensation Health Care Networks or Certain Political Subdivision Health Care Plans Type (or print in black ink) each item on this form I. EMPLOYEE/EMPLOYEE’S ATTORNEY INFORMATION 1. Employee's Name (First, Middle, Last) 3. Employee’s Mailing Address (Street or PO Box, City, State, Zip Code) 4. Employee’s Telephone Number ( ) 7. Attorney/Representative’s Name (if applicable) 5. Alternate Telephone Number (if available) 6. Date of Injury (mm/dd/yyyy) ( ) 8. Attorney/Representative’s Address (Street or PO Box, City, State, Zip Code) 2. Employee’s Social Security Number II. EMPLOYER INFORMATION (at the time of the injury) 9. Employer’s Name 10. Employer’s Address (Street or PO Box, City, State, Zip Code) III. INSURANCE CARRIER INFORMATION 11. Insurance Carrier's Name 13. Adjuster’s Name 12. Insurance Carrier's Address (Street or PO Box, City, State, Zip Code) 14. Adjuster’s Telephone Number ( ) ext. 15. Adjuster’s Fax Number ( ) IV. TREATING DOCTOR INFORMATION Current Treating Doctor 16. Current Treating Doctor's Name (First, Middle, Last) and Title (MD, DO, DC, etc.) 18. Current Treating Doctor's Mailing Address (Street or P.O. Box, City, State...
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...The appeal process is used to challenge a medical claim that has been reduced, denied, or is a down code claim. The appeals process begins when the provider request a review of the payers decision to deny a claim. The person that files the claim is known as a claimant or appellant depending on if it is a provider or patient who files the claim. Procedures for handling medical claim appeals may vary between the payer and the reason for the appeal. There is a required time frame for the appeals process after the claim determination. Most payers have a structure of appeals consisting of the complaint, appeal, and grievance. There are three levels involved during the medical claim appeals process. Most payers require a minimum amount to be set so take is not used for small dispute amounts. The appeal process can result in a reduced or denied payment of a medical claim. There a several reasons a medical claim may be denied by the payer. If the patient has other primary medical insurance or, the patient as a workers’ compensation claim or, an automobile claim there is specific information that is required. The scheduler has to ensure they have the patients’ correct and updated information. Workers’ Compensation and auto accident claims require the patients claim number, adjusters’ name, and all services require preauthorization. An error in relation to this example is considered a billing error. Another example of a billing error is the absence of a referral on file because most...
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...Characteristics of Workers’ Compensation Plans By Vershawn Thompson February 7, 2013 HCR/230 Jill Frawley There are currently two types of state workers compensation benefit plans as well as four different types of federal plans. One of the state workers compensation plans consists of paying for medical expenses. This program allows compensation for the employee if their injury or illness was caused by their employment. The second plan offers compensation for the employee’s wages that are lost during the time the employee is physically unable to work. The state workers’ compensation fund puts premiums into one state based insurance fund. This fund is the source of payment for all claims. In the private plan—which is favored by most employers—employers enter into contracts with private insurance carriers. One of the four federal compensation plans is the Longshore and Harbor Workers’ Compensation Program. This program offers individuals that are working in the maritime industry some coverage. People that develop certain diseases like cancer because of exposure to radiation while working at federally-owned facilities where radioactive materials are accessible are covered under the Energy Employees’ Occupational Illness Compensation Program. Employees of the federal government are eligible for coverage under the Federal Employees’ Program. The Federal Black Lung Program was established...
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...Characteristics of Workers’ Compensation Plans University of Phoenix FOOTING THE BILL HCR 230 Barbara Hopkins July 12, 2013 Workers’ compensation was developed to benefit both the employer and the employees. It provides employees who are injured on the job with compensation for their injuries, and it protects employers from liability for employees’ injuries (Valerius J., Bayes..L.N., Newby.C., Blochowiak. L. A., 2014,). Work-related illnesses or injuries suffered by civilian employees of federal agencies, Including occupational diseases they acquire are covered under various programs administered by the Office of Workers’ Compensation Programs. OWCP is part of the U.S. Department of Labor (Valerius J., Bayes..L.N., Newby.C., Blochowiak. L. A., 2014,). The four workers’ compensation plans that provide coverage to federal government employees are: 1. The Federal Employees’ Compensation Program 2. The Longshore and Harbor Workers’ Compensation Program 3. The Federal Black Lung Program 4. The Energy Employees Occupational Illness Compensation Program States provide two types of workers’ compensation benefits .One pays the worker’s medical expenses that result from work-related illness or Injury. The other pays for lost wages while the worker is unable to return to work. In some states, state benefits just won't be enough to help an injured or ill worker to survive after...
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