Workers Compensation The Clock is Ticking. Wednesday September 23, 2015 Monterey, California. Workers Compensation: The Clock is Ticking

Transcription

1 Workers Compensation The Clock is Ticking Wednesday September 23, 2015 Monterey, California Debbie Yokota SDRMA Claims Manager Presented by Dorienne Zumwalt York Risk Services Group What we will cover today When do I have to give an injured employee a claim form? How long does York have to investigate a claim? When does Temporary Disability start? When does it stop? How long does York have to conduct Utilization Review on a medical treatment request? How long to Permanent Disability payments last? When am I required to offer my employee regular, modified or alternative work? When can a claim be closed? 1

2 When is a claim form required? A claim form, or DWC-1, is required to be given to an injured employee within one business dayof the employer s knowledge of a work-related injury. Investigation Process When the employer or claims administrator questions whether or not an injury is work-related, the claims administrator can place the claim on delay. The delay process is 90 days from the date the employer had knowledge of a work-related injury. Investigation Process For example, if the employer was aware of a possible work-related injury on September 1 st but did not notify the claims administrator until September 15 th, the claims administrator only has 90 days from September 1 st to investigate the claim to determine whether or not to accept the claim. If the employer waited until the 91 st day to notify the claims administrator of an injury, the claim could be automatically considered compensable. It is extremely important to notify the claims administrator as soon as you know of a potential work-related injury. 2

3 Temporary Disability Benefits Temporary Disability (TD) benefits are paid to employees who cannot perform their usual job while recovering from their industrial injury or illness. The two types of TD benefits are: Temporary Total Disability (TTD) Employee is completely off of work for more than 3 days. Temporary Partial Disability (TPD) Employee is able to work part-time in usual job or alternative/modified job. Temporary Disability Benefits Limitations; TD benefits (both TTD and TPD) are limited to 2 years from the date of injury during a 5 year period. (Exceptions are for catastrophic claims such as amputations, severe burns, chronic lung disease, etc.) Temporary Disability Benefits Temporary Disability benefits are paid at 2/3 of the employee s salary with a maximum depending on the year of the injury. While a claim is on delay, Temporary Disability benefits are paid to the employee unless the claim is later accepted. TD payments are issued every 14 days. There are penalties of up to 10% if a TD payment is issued late. 3

4 Medical Treatment All employees are entitled to receive medical treatment for their injuries even during the time their claim is on delay. When a claim is on delay, medical treatment is limited to $10,000 during the 90 day investigation period. Employees are allowed to pre-designate their own personal physicians to treat them for a work-related injury as long as they have pre-designated them prior to the injury, the physician has treated them before the injury, and the physician has agreed in writing to treat the employee for workrelated injuries. Medical Treatment SDRMA uses a Medical Provider Network (MPN) to treat our injured employees. Under the requirements of the MPN, employees must treat with physicians in the MPN unless they have pre-designated. These physicians have been carefully vetted through our vendor to ensure that the physicians follow specific requirements such as easy access for employees, prompt reporting and returning employees to modified duty when appropriate. Without an MPN, the employee can treat with physicians who may be more inclined to keep them off of work or recommend unnecessary medical treatment. Utilization Review Timeframes Utilization review (UR) is the process used to review medical treatment to determine if it is medically necessary. This program is used to decide whether or not to approve medical treatment recommended by a physician which must be based on evidence-based medical treatment guidelines. 4

5 Utilization Review Timeframes The claims administrator must complete the review and make a decision within 5 days of the date the doctor submitted the requested treatment. If additional information is needed to make a decision, the claims administrator can have up to 14 days. Permanent Disability Benefits Most injured workers recover fully from their job injuries but some continue to have medical problems related to their injuries. Permanent Disability (PD) is any disability that results in a reduced earning capacity after being found medically stationary. If the physician finds that the employee has PD related to their work-related injury, they must send a report to the claims administrator. The claims administrator then has 14 days to either pay PD benefits based on a rating of the physician s report or start the Qualified Medical Evaluation (QME) process. Permanent Disability Benefits Permanent Disability benefits are paid to the injured worker until the estimated award or approved award has been paid If the injured worker s permanent disability award is 70% or higher, they receive a lifetime payments equal to their weekly permanent disability payments. For injured worker s with a PD award of 100%, they receive their Temporary Total Disability rate for life. 5

6 Return to Regular, Alternative or Modified Work Requirements For injuries occurring on or after January 1, 2013, the employer has 60 days to make an offer of regular, modified or alternative work to the employee after receipt by the claims administrator of the Physician s Return-To-Work & Voucher Report. Conditions for Offers to Work The employee is able to perform the essential functions of the job. The job is a regular position lasting at least 12 months. The job offers wages and compensation that are at least 85% of the original wages and compensation at the time of the injury. The job is located within a reasonable commuting distance to the employee s residence at the time of injury. Closing a Claim There is a saying in workers compensation: The only good claim is a closed claim 6

7 Closing a Claim So when can a claim be closed in worker s compensation? When the employee only receives medical treatment: the claim can be closed when the treating physician says the employee is medically stationery and discharged from care. When the employee receives temporary disability or permanent disability benefits or requires future medical treatment after being found medically stationary: the claim must be settled by Compromise and Release or Stipulated Award with Future Medical Award. Workers Compensation Claim Settlements Stipulations: Settles out Permanent Disability and is paid out in bi-weekly checks Usually offers the injured worker lifetime future medical benefits for the affected body part If condition worsens, injured worker has the right to reopen for New & Further Disability within 5 years from the date of injury. Medical benefits can be settled out at a later date via Compromise and Release. Compromise & Release: Settles out permanent disability, future medical treatment and the right to reopen the claim. Paid out in a lump sum payment less any previous advance made during the claim. Questions? Please contact Debbie at or Debbie at dyokota@sdrma.org. Thank you for your participation today! 7

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