The Worker s Compensation Process

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1 Workers Compensation Basics The Worker s Compensation Process Kenda Weigang MARCH 2015

2 What should be posted Workers Compensation ACT Notice to Employees Authorized Treating Physician (ATP) Notification and List Post information in an area that is easily viewed by employees

3 Injuries happen..what should you do? Is it an Emergency? Yes In case of life or limb-threatening emergency call 911 or go immediately to the nearest care facility. Employee will need to follow up with one of CSU s Authorized Treating Physicians (ATP) If it is after hours or while traveling, go to the nearest urgent or emergency care facility. No Complete a first report of injury and seek care with ATP

4 Emergency Follow-up If the initial medical care is obtained from an Urgent Care facility the employee will need to provide the provider the following billing information. Cannon Cochran Management Services Inc. (CCMSI) P.O. Box 4998 Greenwood Village, CO Phone: (303) Fax: (303) Toll-Free: (888) Employee will also need to seek follow up care through one of the ATPs. If an employee doesn t provide the care facility with CCMSI s billing information or if the employee seeks medical treatment outside of the ATP they are likely to be billed and personally responsible for the cost. If ER or Urgent care is obtained and the claim isn t deemed work related the employee with be responsible for all bills and services.

5 eport The Event All injuries and incidents should be reported immediately to the employee s direct supervisor who will notify the appropriate parties and assist in completing the first report of injury. A first report of injury needs to be filed within 24 hours You will need the affected employee s CSU Id number to complete the report Hand delivered to Risk Management located at 140 General Services Building Faxed to Attn: Kenda Weigang

6 Incident or Injury what s the difference? Incident An incident is an accidental work injury or exposure that does not require a licensed medical service provider to provide care for the condition (first aid only), and there is no lost time from work, permanent disability or death. An incident report notifies the employer that a worker had an accidental injury or exposure that may result in a claim or need for medical treatment in the future. Injury An injury claim is an accidental work injury or exposure that does require a licensed medical service provider to provide care for the condition, resulted in death, or may require lost time from work. Out of State This report is for employees who live and are employed out of state If an employee is injured while out of state on business but primary work location is in Colorado this is not considered and out of state claim

7 Types of Injury Claims Medical only claim Claim in which medical treatment is received but missed time from work does not exceed the first 3 work shifts Indemnity claim Claim in which wage replacement benefits are due and paid pursuant to the Workers Compensation statute

8 First Report Essentials Employee s current phone number and mailing address Job title and department Position- Hourly, full time, part-time, special assignment 9 month, intern.. Normal Work Schedule Witnesses name/names Detailed information regarding the injury. How When Where What was the injury of exposure Be specific on body part.. Review the report for accuracy prior to pushing the submit button Make a copy for your file work comp information must be kept separate from employee s personnel file Take pictures if possible

9 Once Claim is Filed CSU &/or the insurance company's adjuster. contacts the employee, the department and gathers medical and other pertinent information regarding the injury. An information packet will be sent out to the employee from the TPA / carrier explaining benefits, and should include a prescription card and mileage reimbursement form. There will also be a medical release in the packet. While it is a Kaiser Medical Release it does apply to all injuries and should be completed and returned. CSU Risk Management team works with the employee, department, adjuster and medical provider to gather information. They also assist in return to work, claims management and progression of the claim. Depending on the nature of the claim it maybe sent to the loss control team or Environmental Health Services personnel for review, site visit or further investigation The claim will then be either accepted, denied, or placed on a Notice of Contest.

10 Once a claim is filed Risk Management reviews and forwards to our TPA or out of state carrier CSU is self insured for in-state claims A Third Party Administrator (TPA) handles our claims Out of state claims are covered by an insurance carrier. The TPA is responsible for: Assigning an adjuster Filing all applicable paperwork to the Division of Labor Obtaining medical information from medical providers, authorizing medical treatment and processing related bills. Admitting or denying the claims based on the Workers Compensation Statute Working closely with CSU and the employee to ensure the claim runs smoothly

11 Claims Status Explanation Denial - Accepted - Claim deemed not work related Claim is deemed compensable Notice of Contest(NOC) Claim hasn t been accepted or denied as further investigation is needed. IT IS VERY IMPORTANT if an employee receives a NOC that they read the NOC. TYPICALLY the claim is on NOC because something needs to be done. Sometimes something as simple as the employee not calling the adjuster to complete the first report of injury investigation can cause a NOC. If a NOC is filed the employee s wage replacement, modified duty and medical are either cut off or jeopardized until the unmet items are completed.

12 RETURN TO WORK CSU s Goal is return to full duty Return to work plan Work conditioning Job analysis Clinical Fit for Duty Testing Release by the physician without restrictions Preventing further injury

13 Return to Work following an injury Employee returns with medical report from physician appointment. The injured employee should deliver a copy of the medical provider s work status report to his/her supervisor following the visit. If the employee goes to the ER or other provider, they may not have a work status report. If the claim is deemed not work related the employee will be referred to his/her personal physician and the work comp claim will be closed - The employee should follow-up with their departments Human Resource Representative or CSU s HR to see if they have other benefits for personal injury issues. If employee returns without restrictions - they should continue to perform their full duty. If they have difficulties they should return to the physician. If the employee has restrictions: The Supervisor and other pertinent parties review work restrictions and evaluates whether the department can utilize the employee within their restrictions (Risk Management is available to assist you in this process). Modified duty does not have to comply with the workers normal work schedule or duties. It will be designed according to work tasks available at CSU and within employees outlined restrictions.

14 Return to work with restrictions If the employee has restrictions, please assess whether your department can use them. If so, please complete the modified duty letter. If modified job offer is documented and employee doesn t return their wage loss benefits may be discontinued or reduced. Notify WC office (970) if any resistance by employee to return to work (a certified letter in accordance with Rule 8 will be complete in order to stop wage replacement. Employee should continue to work within their restrictions and the same personnel rules and regulations of all employees apply There are RTW funds available to assist departments to cover the cost of offering temporary modified duty. The RTW funds also cover the 1/3 not covered by WC lost time reimbursement. Job duties need to increase as restrictions lessen and full duty is reached. We have a loan closet of equipment

15 Temporary Modified Duty RTW can be in the employees regular job doing regular tasks, alternative tasks or in a different area. Steps to take for RTW: Complete temporary modified duty (MD) job offer letter. This is available at Forms: Supervisor and employee review and sign Employee Injury Guide(if not previously completed, whether or not they will be returning to your department. Also available on line at : Send copies of both to Kenda Weigang at Or bring by: 143 General Services Building.

16 Modified Duty Employees brought back to work with restrictions can include part-time work In own department or through Risk Management s Return to Work program Consistent approach with all employees Consideration given to Probable duration Probable recovery to full duty We can assist in coming up with options or outlining job tasks for the physician to review.

17 Temporary modified duty in alternative departments A number of departments can utilize employees while they are recovering The employee is still a member of their department A gradual return to work program can be possible Goal is the return to full duty Home department is still responsible for the reporting of lost time

18 Temporary Modified Duty in Alternative departments A number of departments can utilize employees while they are recovering. The employee is still a member of their department but required to adhere to the hours and duties as outlined in the modified duty letter. A gradual return to work program can be possible. Goal is return full duty Home department is still responsible for reporting missed time and developing an internal process of gathering such. Employees still need to turn medical notes to home supervisor and meet with them on a weekly basis. Employee should also be invited to attend departmental meetings, events and trainings. Employees placed elsewhere on campus are paid out of RTW funds and not home department

19 Employee Guide Points to Remember Unless employee is taken off work by one of CSU s Authorized Treating Physicians(ATP), the employee is expected to continue to work. After reviewing work status report, employee may continue to work in department, performing work within their physical abilities or be placed temporarily elsewhere within the CSU system. If employee is released to return to work, whether modified duty or full duty, and chooses not to return to work, the employee may jeopardize injury wage replacement benefits. Any time taken would be personal leave. An employee shouldn t be sent home because of complaints of pain. Instead they should return to the physician if they don t think they can complete job tasks. If an employee does not wish to see the doctor, related time missed from work will be annual, sick or leave without pay.

20 Employee Guide Continued Employees are expected to report to work before and after medical appointments, when scheduled during working hours in order to be paid for the day and for appointment time. We encourage you to make appointments before or after your work shift. In order to be paid for time missed from work due to your injury, you must turn in lost time to your supervisor or department s payroll person, along with medical documentation for the missed time. Without documentation from the medical provider that you attended an appointment or were taken off work, you will not be granted paid injury leave.

21 TIME MISSED Wage replacement benefits Benefits as outlined by the WC Statute Injury leave benefits Benefits provided for BENEFITTED State of Colorado Employees Tracking and payment process for both

22 Benefits overview WC insurance is provided by employers at no cost to employees. If you are injured on the job or sustain a work related illness or disease; compensation and medical costs are paid as provided by state specific Workers Compensation laws. At CSU if you are an hourly employee you are provided all the benefits of the statute and paid directly in accordance to the statute (if applicable) If you are a Benefitted Employee CSU provides an additional benefit through Injury leave. As part of Colorado State University s benefits package, CSU offers Injury Leave to eligible employees which provides for full salary replacement during periods of absence for compensable claims under Workers Compensation. Injured employees must turn any wage reimbursement benefits allotted to them by the insurance carrier, over to CSU, to be eligible for full salary replacement under the Injury Leave policy.

23 Reporting Lost Time What is reportable missed time: Actual time missed from their work schedule that was related to attending a medical appointment Time taken off work by the (ATP) Time missed due to CSU not having work within the restrictions outlined in the Medical Status report The first 24 hours are the employee s own time, but still needs to be reported If medical treatment is sought day of injury, missed time for benefitted employees is Administrative Leave. Please note that time away that doesn t occur during your normal work schedule or affects the employee s work hours should not be counted as injury leave time. When possible and work schedule allows, appointments should be made outside of work. Injury leave will cover only time that is medically documented and only for reasonable time to get to and from the appointment and during the employee s scheduled work hours.

24 In Permanent Employee Injury Leave One of the benefits that the State of Colorado provides to their full time benefited employees is Injury leave for employees missing time from work due to a job-related injury/illness A qualified full time employee who incurs a work-related injury or illness that qualifies for workers compensation benefits is granted up to 90 (instances) of injury leave/lost time with full pay for qualifying and documented time away from their normal work schedule. What does that mean/how does it work? The department turns in the lost time to the WC Program WC turns the time into our TPA or carrier For instate claims - Our TPA cuts a check for the 66 2/3 and sends it to CSU. This check is credited into the account paying the employee s salary The balance (1/3) is paid by the department or RTW program (during the first 90 instances) If an employee receives a wage check from the TPA/carrier during this time they need to turn it into CSU or it will be taken out of their check. Out of state carrier may pay the employee directly and the employee must turn over their checks in order to receive the benefit

25 How to Report Lost time Employees are expected to report lost time weekly to their supervisor. The Department should utilize the COLORADO STATE UNIVERSITY - WEEKLY Workers' Comp Time Sheet.. Employees/Supervisors should turn in WC time sheets weekly to Department s payroll Liaison and WC program with medical documentation attached for time off. Time sheet can be faxed to (970) , ed to We ask that the time be submitted no later than Tuesday of each week, with medical documentation of appointments attached. Time off that isn t documented by a medical record or no work available will not be covered under WC Failure to report lost time in a timely manner can result in penalties to the university and

26 Injury Leave is not granted when:. A determination is made that the injury or illness was caused by willful misconduct of the employee or by willful disobedience of reasonable rules and regulations resulting in reduction of compensation payments.. The physician determines the injury is non work related. The claim is placed on a Notice of Contest, regardless of reason, until it is deemed compensable It is important that this is followed and the employee cooperates with TPA to get needed information so that a determination of benefits is made ASAP. Until the claim is accepted the employee will need to use their own time. If employee is at MMI or released from care If an employee returns to the doctor for maintenance treatment following MMI (maximum medical improvement) this is on their own time versus injury leave

27 Release from Medical Care The overall goal is recovery and return to full Duty At a point in the claim the employee will be placed at Maximum Medical Improvement(MMI). This is a point at which the physician feels that regular and ongoing medical treatment isn t needed. The employee may or may not continue to improve but can do treatment modalities without on-going medical Supervision/treatment. At the point of MMI the employee will be released full duty or with restrictions.

28 MMI Maximum Medical Improvement Once an employee has reached maximum medical improvement (MMI) and is released from medical care they will either have a full duty release or be given permanent restrictions. The employee must contact their supervisor and provide them with a copy of the final physician s report immediately. Employees that are placed at MMI for failure to comply with medical treatment should not be allowed to return to work without adequate medical treatment and evaluation of abilities. An employee who reaches MMI without a full duty release, should not be allowed to return to work until the appropriate departmental staff are consulted, along with human resources and the workers compensation team, to assess the employee s ability to perform the essential functions of their job. MMI with Maintenance care: Some follow up care is outlined in order to complete treatment and/ or maintain status. Payment for medical treatment is covered Missed time from work for maintenance care after MMI is not covered.

29 Please reference Risk Management s website periodically for additional information AND updated information Remember Risk Management is here to assist you

30 Claim Closure A claim can be closed for a number of reasons Released from medical care Released due to non compliance with care If released for non compliance, don t allow employee to work as you don t know their restrictions. (time off until restrictions provided is employee s own time) Released at Maximum Medical Improvement (MMI) If released full duty/no restrictions - continue to work If released with permanent restrictions - do not allow them to work, contact HR. If MMI with maintenance they may have periodic visits for medications, finish up with therapy During this time medical benefits are paid but no wage lost benefit provided. If the claim has been an indemnity claim the employee will receive a Final Admission of liability This Final Admission outlines all payments paid in the claim, the Permanent Impairment rating, if any and payment schedule.

31 Once the claim is closed, a Final Admission is filed with the DOWC. The employee has 30 days to contest the FA if he/she doesn t agree with the admission Depending on the claim, the employee may get an impairment rating and money for the injury, this money is not CSU s but the employees If an employee has problems following claim closure and they feel it is related to prior injury they should contact Kenda at (970) or CCSMI and we may authorize them to return to the authorized provider (usually the one they treated with previously) for a one time evaluation. Missed time for this appointment is not reimbursed under the claim. If the TPA or physician do not reopen the claim, the employee can pursue reopening through the Division of WC (303) or by fax at (303) in the Denver metro area, or toll free at (888)

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