An Injured Workers Guide to the Workers Compensation Process Table of Contents

Transcription

1 An Injured Workers Guide to the Workers Compensation Process Table of Contents I. Claim Information A. General Information 1. What is workers compensation? 2. How do I know if I qualify for Workers Compensation? 3. What steps should I take if I m injured while working? 4. What kinds of injuries are covered by Workers Compensation? 5. What kinds of benefits will I received? 6. Should I be represented by an attorney? 7. Can I sue my employer instead of filing for workers compensation? 8. What if my employer tells me not to file a worker s compensation claim or threatens to fire me if I do? B. Filing a claim 1. How do I file a claim? 2. What does date of injury mean? C. Processing a Claim 1. How long does it take to process a claim? 2. Is there a limit on the lifetime of my claim once it has been filed? 3. Who is responsible to obtain the needed information to allow my claim? 4. What information is needed to allow my claim? D. The Hearing process 1. Why was my claim disallowed? 2. What if my claim or treatment is disallowed/denied, is that decision final? II. Medical Information A. Physicians

2 1. Can I go to any doctor I want? 2. How will I know if a doctor is BWC certified? B. Treatment and Bills 1. How do I get my medical bills paid? 2. What should I do if I receive a bill? C. Managed Care Organizations (MCO) 1. What is the difference between the BWC and an MCO? D. Prescriptions 1. Can I be reimbursed for prescriptions I pay for? 2. My health insurance paid for my prescription but I had to pay a copayment. Can I be reimbursed? III. Compensation Information A. General Questions 1. Will I be paid for the entire period of time I m off work? 2. How does the BWC determine how much I will be paid while I am off work? 3. What if I return to work after being declared permanently and totally disabled? 4. Can I settle my workers compensation claim? 5. If I was receiving workers compensation benefits and I return to work are there any workers compensation benefits I am still entitled to? 6. Are workers compensation benefits taxed? B. Checks 1. Why do the amounts of my checks vary? 2. How long before my money goes directly to my bank? IV. Glossary

3 I. CLAIM INFORMATION A. GENERAL INFORMATION 1. What is Workers Compensation? Workers Compensation is made up of medical and compensation benefits. These benefits are available to any worker that has been injured on the job. When an injured worker files a worker s compensation claim they are not suing their employer. Instead, it is like the injured worker is filing an insurance claim against their employer. 2. How do I know if I qualify for Workers Compensation? If you are injured while doing your job, then you qualify to apply for workers compensation benefits. A work related injury does not always guarantee you Workers Compensation benefits. 3. What steps should I take if I m injured while working? First, if immediate medical attention is not necessary, you should notify your employer. Fill out an accident report describing the incident and listing every part of your body that was injured. Second, you should go to the doctor. The doctor will document the injury and diagnose your conditions. This is an important step; if a condition is left out it could be difficult to add it later. If you do not have a medical provider or need immediate assistance, go to the nearest urgent care or hospital ER. 4. What kinds of injuries are covered by Workers Compensation? Any injury that occurs while performing your job is covered by Workers Compensation. The injury must be a direct result of the accident or the accident must be so traumatic that it makes a previous condition worse. 5. What kinds of benefits will I received? All injured workers with allowed workers compensation claims are entitled to payment of medical bills related to treatment of the work related injury. An injured worker may also be entitled to compensation as well. Such as: Temporary Total Compensation (TT) Wage Loss Compensation Permanent Partial Disability (PP) Permanent Total Disability (PTD) Lump Sum Settlement Awards

4 6. Should I be represented by an attorney? The Workers Compensation system is complex. No two claims are alike. Two workers could be injured in the same way, on the same day, at the same time, at the same place of employment. They could receive the same treatment from the same doctor. While all this is the same, both workers will have completely different outcomes. An attorney will help you navigate the system to achieve the best possible outcome. 7. Can I sue my employer instead of filing for workers compensation? Generally no, Workers Compensation is a no-fault system. Employers are required by law to pay premiums into the compensation system. This protects the employer from being sued and ensures employees coverage. For this reason, an injured worker MAY ONLY collect compensation from their employer at the time the injury occurred. If you were harmed by someone other than your employer you may be able to sue that person. This is far more complex and would require the help of an attorney to protect your rights. 8. What if my employer tells me not to file a worker s compensation claim or threatens to fire me if I do? This is a violation of Ohio law and should be discussed with an attorney to assure your rights are protected. B. FILING A CLAIM 1. How do I file a claim? The injured worker must fill out the FROI-1 form. This form has a section for personal information about the injured worker and a section that MUST be filled out by a medical provider to document the injuries. When this form is complete and submitted to the BWC the process officially begins. 2. What does date of injury mean? The date of injury refers to the date the injured worker was hurt while working.

5 C. PROCESSING A CLAIM 1. How long does it take to process a claim? Once the FROI has been received the BWC will investigate the claim. A decision will be reached within 28 days from the date the FROI is filed. 2. Is there a limit on the lifetime of my claim once it has been filed? The lifetime of your claim is determined by the date of injury. The actual determination of time limits is complex. An attorney will best be able to monitor the life of your claim to ensure maximum compensation or medical treatment. 3. What information is needed to allow my claim? The necessary documentation varies by claim. Usually the following information is needed: Name and address of the injured worker Employer name and workers compensation policy number Detailed accident description Medical diagnosis of an injury Medical documentation to support the relationship of the treatment to the work related injury or occupational diseases Information regarding disability 4. Who is responsible to obtain the needed information to allow my claim? The Managed Care Organization (MCO) is supposed to act as a link between the BWC and the injured worker. However, to ensure fair representation an attorney will work with you and your medical provider(s) to make sure all medical information is received by the BWC. D. THE HEARING PROCESS 1. Why was my claim disallowed? All claims are different and will have different reasons for disallowance. Most of the time it is for lack of information. An attorney will be able to work with you and your medical provider(s) to obtain the necessary information to support your claim. 2. What if my claim or treatment is disallowed/denied, is that decision final? The decision is not final until either the industrial commission or a staff hearing officer rules. Knowing when a final decision has been made can be confusing. An attorney will help you navigate the process so that your rights are protected.

6 II. MEDICAL INFORMATION A. PHYSICIANS 1. Can I go to any doctor I want? The rules governing the program provide that the injured worker has the right to be treated by the doctor of their choice so long as the doctor is a BWC certified provider. Note: if your employer is self-insured you should contact the employer to obtain information about choosing a physician. 2. How will I know if a doctor is BWC certified? You can contact the BWC to see if a doctor is certified or seek the advice of your attorney for BWC certified physicians in your area. B. TREATMENT AND BILLS 1. How do I get my medical bills paid? Once the claim is allowed the providers (not Pharmacies) who have treated you for the work related injury should submit their bills to the MCO. The MCO reviews the prices and the bills and forwards them electronically to the BWC. The BWC pays the MCO who in turn disburses payment to the medical provider. 2. What should I do if I receive a bill? Forward the bill to you attorney, if you have retained one, or send the provider your MCO s information. C. MANAGED CARE ORGANIZATIONS (MCO) 1. What is the difference between the BWC and an MCO? The BWC is a State of Ohio government agency, responsible for Ohio s workers compensation system. The MCO is a private company selected by or assigned to each state-funded Ohio employer to medically manage the employer s workers compensation claims. The BWC makes all final decisions regarding claim allowances and treatment disputes. It also issues benefit payments. The MCOs coordinate medical care and make treatment decisions.

7 D. PRESCRIPTIONS 1. Can I be reimbursed for prescriptions I pay for? If the pharmacist sent the bill information to the PBM when dispensing your prescription you do not need to do anything. You will be reimbursed once your claim is allowed. If you paid for your prescription as a cash customer and the bill information was not sent to the PBM, then you would need to have your pharmacist complete a specific reimbursement form. 2. My health insurance paid for my prescription but I had to pay a copayment. Can I be reimbursed? No. Any prescriptions relating to the work injury should be submitted to the PBM. BWC cannot reimburse you for co-payments.

8 III. COMPENSATION INFORMATION A. GENERAL QUESTIONS 1. Will I be paid for the entire period of time I m off work? You will be eligible for lost time benefits if you lose more than seven days of work. Also, the first seven days are not payable until you lose 14 consecutive days. Other than these exceptions, most injured workers are usually paid for the entire period of time they are off. If an injured worker is off work for three months (90 days) a medical exam may be scheduled. Continued payment of temporary total disability will be dependent on the outcome of the independent medical exam. 2. How does the BWC determine how much I will be paid while I am off work? Compensation rates are based on your earnings prior to the injury taking into account the minimum and maximum rates applicable to the year you were injured. 3. What if I return to work after being declared permanently and totally disabled? As implied by the name, the expectation is that the injured worker s inability to work is permanent. Should an injured worker who has been declared PTD return to work, the injured worker must notify the BWC immediately. Benefit payment would cease at that time. Continued receipt of PTD benefits after a return to work is illegal in most cases and could subject the injured worker to prosecution for fraud. 4. Can I settle my workers compensation claim? OhioBWC claims may be settled if all parties (Injured Worker, Employer, and the BWC) to the claim agree to a settlement. Before any claim is settled, an Injured Worker should consult an Attorney. Settling a claim is a final event which closes the claim for a lump sum of money. This lump sum is in exchange for the injured worker giving up their rights to seek future medical expenses, treatment, and compensation of any type. Be aware that the Employer and the BWC are in a better position than an unrepresented injured worker to settle the claim. The BWC now sends out settlement inquiries to injured workers. This is aimed at closing cases and saving the BWC money. Having an attorney will protect your right to what you are owed.

9 5. If I was receiving workers compensation benefits and I return to work are there any workers compensation benefits I am still entitled to? When an Injured Worker returns to work with restrictions, whether it is at the job where the injury took place or a new job, the injured worker may be entitled to wage loss compensation. 6. Are workers compensation benefits taxed? Ohio does not tax money awards received from the OhioBWC claims. The federal government does not tax OhioBWC compensation benefits. B. CHECKS 1. Why do the amounts of my checks vary? There are many reasons why the amounts of your workers compensation checks may vary. Generally, checks are paid in two week increments. Sometimes due to the beginning and ending dates on the form completed by your physician, there may be a variance in the amount of the checks received. Also after the first 12 weeks of temporary total the amount will change. An attorney can explain more about specific changes and why they have occurred. 2. How long before my money goes directly to my bank? The first step is to sign up for direct deposit by completing the ACT enrollment form, attaching a voided check or deposit slip and fax them to or mail them to: Accounts Payable ACT Bureau of Workers Compensation PO Box Columbus, OH Once the BWC processes the authorization, it takes about six business days for your bank to verify the bank account information. The BWC will send you a letter explaining the effective date of your authorization. After that date, any payments, made to you by the BWC will be deposited into your account.

10 IV. GLOSSARY A. MEDICAL TERMS 1. IDC-9 Code ICD-9 Codes are three, four or five-digit numeric codes that represents a uniform, international classification system of coding disease and injury diagnoses and are used to report allowed, non-allowed or disallowed/denied conditions. 2. Maximum Medical Improvement ( MMI ) MMI is a treatment plateau in each person s healing process. It can mean that the patient has fully recovered from the injury or that the patient s medical condition has stabilized to the point that no major medical or emotional change can be expected in the injured workers condition. This occurs despite continuing medical treatment or rehabilitative programs the injured worker partakes in. 3. Additional Allowance or Additional Condition ( AA ) An additional condition or disease may be allowed subsequent to the initial allowance if there is evidence to support a causal relationship between the allowed injury and the new condition or disease. B. COMPENSATION TERMS 1. Permanent Total Disability ( PTD ) This is the injured worker s inability to perform sustained remunerative employment due to the allowed condition(s) in the claim. The purpose is to compensate the injured worker for impairment of earning capacity. Compensation for PTD is payable for life. When an injured worker applies for permanent total disability, he/she must attend an Industrial Commission examination and hearing to determine if he/she meets the eligibility criteria for this type of compensation. 2. Temporary Total Disability ( TT ) TT compensation is provided to compensate an injured worker who is totally disabled from work on a temporary basis or a short period of time due to the work related injury or occupational disease. TT is generally the initial award of compensation paid to an injured worker to compensate for lost wages.

11 3. Permanent Partial Disability ( PP ) A certain amount of permanent damage (called residual damage) may remain as a result of the injury and is compensation awarded for residual impairment resulting from an allowed injury or occupational disease. For example, if an injured worker sustains a broken arm and can no longer extend it to the full degree, he would be eligible for an award based upon the residual loss. The permanent impairment may be physical, psychological or psychiatric. 4. Violation of a Specific Safety Requirement ( VSSR ) No employer will violate a specific workplace safety requirement established by legislation or BWC. The injured worker (IW) or dependent, (when there has been a fatality) may file an application for a Violation of Specific Safety Requirements (VSSR) award if there is evidence that a violation has or may have occurred from the failure of the employer to comply with a specific safety requirement. 5. Wage Loss ( WL ) Wage Loss compensation may be paid to an injured worker (IW) that suffers a reduction in earnings as a direct result of restrictions from the allowed conditions in the claim Two conditions must be met to be eligible for WL. A loss or decrease in wages exists. The wage loss is a direct result of the restrictions caused by the allowed conditions in the claim. There are two types of wage loss benefits that may be considered in a claim. Working Wage Loss (WWL): This is payable when the IW returns to employment other than his or her former position of employment. This would include return to work with the employer of record or a new employer with different job duties, less hours and less pay resulting from the physical restrictions. Non-Working Wage Loss (NWWL): This is payable when the IW is unable to find suitable employment. In order to qualify for NWWL the injured worker must demonstrate that he/she is making a good faith effort to secure employment within his/her physical restrictions. 6. Lump Sum Settlement ( LSS ) The payment of an entire debt all at once rather than in installments; a payment for a debt or claim in its entirety is made one time. The payment wipes out any further demands or claims made by a party on another for accepting the settlement. Even if there is a change of mind after the fact, the payment bars any return of the issue legally

12 C. THE PROCESS/ FORMS 1. FROI Injured workers, employers or medical providers use this form to initiate a worker s compensation claim. The party completing the form should supply BWC with as much detailed information as possible. An electronic version of the FROI is available for filing online. 2. BWC Order A BWC Order is the written notification to all parties of the claim of the decision the Customer Service Specialist (CSS) has made from the evidence that has been gathered during the investigation of a claim. BWC Orders provide a consistent, standard format that is user friendly and similar to the format and language used in IC Orders. The purpose of the BWC Order is to: Communicate claims decisions in clear common language to the general public; Provide due process to all parties of the claim. 3. IC Order An IC Order is written notification to all parties of the claim of the decision of the Hearing Officer based on the evidence submitted. If not appealed these orders become binding. 4. Staff Hearing ( SH ) This is the second level hearing for the IC. Usually the decision of this hearing officer is binding. The Injured Worker has two choices to appeal the IC and get a third level hearing. Or, in most cases, the IC will deny a third level appeal and the Injured Worker can appeal into Court. 5. District Hearing ( DH ) This is the first level hearing for the IC. It is an appealable order that will only become binding after the appeal period has run. 6. C23 Injured workers should use this form to notify their managed care organization (MCO) of a change of POR. Injured workers must choose a physician who is BWC-certified. The physician will receive payment only for medical services and items related to the treatment of the allowed conditions in the injured workers claim and in accordance with the MCO's medical management guidelines. Injured Worker's can also use this form to notify self-insuring employers of a change of physician

13 7. C84 Injured workers and their physicians must use this form to initiate or extend payment of temporary total disability benefits. The injured worker provides information about employment and benefits received during the time of disability. The physician provides information about the condition, physical restrictions, objective and subjective findings, maximum medical improvement, vocational rehabilitation and the dates of disability being certified, including an estimated or actual return-to-work date. This form advises both the injured worker and the physician of the penalties associated with workers compensation fraud. 8. C86 Any party to the claim can use this form to request action on a claim from either BWC or the IC (i.e., allowance of additional condition(s) and/or benefit payments). This form should always be submitted with supporting documentation such as medical evidence. 9. C9 Medical providers use this form to supply information to managed care organizations (MCOs) or self-insuring employers and to request authorization for additional treatment. Information includes: the current diagnosis; additional conditions felt to be related to the industrial accident/exposure; causal relationship of conditions to the accident/exposure; pre-existing conditions, disability and treatment plan. If a physician requests additional treatment, he/she must indicate the specific type, frequency and duration of the treatment. 10. C92/ C92A Injured workers should use this form to request a determination relative to a permanent disability which they have as a result of their work-related injury or disease. The initial application for permanent partial disability may be submitted 40 weeks from the date of injury or 40 weeks after the last date of disability compensation. There is no time constraint for filing for an increase. 11. Medco-14 Injured workers use this form to apply for wage loss compensation.this form is completed by the injured worker and the physician of record. The injured worker supplies information regarding the current work status and employment history. The physician provides information regarding the injured worker s work restrictions and physical capacity. Completed forms should be sent to BWC or the self-insuring employer.

14 D. PARTIES INVOLVED 1. Third Party Administrator ( TPA ) Is an authorized representative who is selected by or hired by the employer to represent their interests during the life of the claim. 2. Managed Care Organization ( MCO ) The MCO is a vendor who contracts with BWC or employer to provide medical management and cost containment services. 3. Opposing Council ( OC ) If the authorized representative for your employer is an attorney. Then they are referred to as opposing council. 4. Physician of Record ( POR ) Although an injured worker can receive services from more than one provider (i.e., treating providers), a physician of record is responsible for assuring that timely, appropriate care is being requested and delivered. A claim may only have one physician of record. A physician of record must be a medical doctor, a doctor of osteopathic medicine, a doctor of mechanotherapy, a doctor of chiropractic, a doctor of podiatry, a doctor of dental surgery or licensed psychologist. 5. Bureau of Workers Compensation ( BWC ) The BWC is one arm of the Ohio Workers Compensation System. It is the administrative and insurance arm of the system, and provides workers' compensation insurance coverage for employers and employees in the State of Ohio through a State fund. Its mission is to protect injured workers and employers from loss as a result of workplace accidents, and to enhance the general health and well-being of Ohioans and the Ohio economy. 6. Industrial Commission ( IC ) The IC the second branch of the Ohio Workers Compensation System. It hears and decides contested workers compensation claims. In addition to hearing claims, it establishes hearing policies, and has original jurisdiction on claims matters, such as determining levels of disability and resolving disputed claims issues. 7. Pharmacy Benefits Manager ( PBM ) The PBM is the vendor the BWC has selected to process outpatient medication bills. Pharmacies submit bills for prescriptions electronically to the PBM. The PBM has access to BWC claim information and approves or denies bills accordingly. The PBM issues payment for prescriptions directly to pharmacy providers and injured workers. BWC's PBM is SXC Health Solutions (SXC).

15 8. Self Insured Employer ( SI ) Self-insuring employers pay workers' compensation benefits directly to their employees. If your employer is self-insured, file your workers' compensation claim with your employer. 9. State Fund Employer ( SF ) State-fund employers primarily are either a public or a private employer who pays premiums for workers compensation coverage; the premiums are placed in the state fund. Two-thirds of Ohio's employers are either public or private employers and are covered by the state fund 10. Case Manager This is your specific contact at Willis and Willis. This individual works with the attorney s to file motions, interact with your physician about treatment, and follow up on forms. This person will help answer your specific claim questions while the attorney s are out of the office or helping another client. 11. Rehab Case Manager Professionals, who specialize in vocational rehab, develop and coordinate these services. Vocational rehab benefits the injured workers through programs that assist them in returning to work and maintaining their jobs.