County of Alameda Risk Management Unit Workers Compensation 101

County of Alameda Risk Management Unit Workers Compensation 101

County of Alameda - Self Insured Self-Insured Program: All benefits are funded directly by County of Alameda and administered by Third Party Administrator (TPA) currently, Sedgwick CMS 2

Understanding Workers Compensation and When an Injury Occurs 3

Types of Injuries Specific - One event at work (may be first aid claim) Example: Slip and Fall accident Cumulative Injury Repeated exposures at work Example: Carpal Tunnel Syndrome Physical or Mental Emotional condition caused by work Example: Stress Claim Occupational disease Chronic ailment as a result of work Example: Some Cancers Exposure to toxic substances Exposure to chemicals at work Example: Asbestos 4

First Aid Claims Any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one time treatment, and follow-up visit for the purpose of observation, is considered first aid even though provided by a physician or registered clinician. 5

Time starts ticking.. KNOWLEDGE: awareness by an employee in a supervisorial position from any source of employee injury claimed or believed to be caused or aggravated by work 6

Who Reports a Claim? Employee (within 1 year of incident) Employer/Supervisor (within 24 hours of knowledge) Medical report (Doctors1 st Report of Injury) Attorney (Application for Adjudication) Benefit provider (lien claimant) 7

Employee s Responsibilities Promptly report injury to direct supervisor. Complete the employee portion of the DWC-1 and return it to the supervisor. Cooperate with the Claims Administrator. Seek medical treatment at designated facility or pre-designated physician. Follow doctor s orders and give supervisor Work Status Report after every appointment. 8

Supervisor s Responsibilities Report injuries within 5 days of knowledge. Complete Form 5020 and send to your Claim Administrator with documentation such as witness forms, confidential memos, etc., to help with the investigation of claim and to report first aid/incident only claims. Provide injured employee with DWC-1claim form within 24 hours of notice of injury from any source. This form is mandatory for non first aid claims and where the injury results in lost time and/or continued medical treatment. 9

Supervisor s Responsibilities continued. Arrange for immediate, appropriate medical care at designated facilities unless an employee has a pre-designated physician. Provide FACTS brochure to injured employee and document in Box #14b of Form 5020 that FACTS brochure was provided. Give the Rx First Fill Notice to the injured employee so they can obtain prescriptions at no cost. Instruct the injured employee to identify themselves as an employee of County of Alameda and provide them with our third party administrator s information when they seek medical treatment. 10

What makes an injury compensable? Injuries, illnesses and conditions which, more likely than not, Arise Out of and in the Course and scope Of Employment (AOE/COE) 11

What happens after an injury is reported? The TPA Claims Administrator: Contacts the injured employee, supervisor and doctor to obtain facts. Determines if injury meets AOE/COE requirement. Advises injured employee by letter if claim is delayed, denied or accepted, within 14 days of claim reported date. 12

A claim may be DELAYED, if additional information is needed... The TPA Claims Administrator: Informs the injured employee of the reason for the delay. Obtains and reviews medical records, personnel, and other employment information. Obtains recorded statements from supervisor, employee and witnesses. Obtains background check to determine prior injuries reported. Arranges for employer-paid medical examination (QME). Makes AOE/COE decision within 90 days of knowledge of the injury based on factual, legal, and medical information obtained. 13

Although the claim is delayed, per Labor Code, appropriate medical treatment will be authorized up to $10,000, subject to UR and ACOEM Guidelines. 14

What are UR and ACOEM? Utilization Review (UR) Review, approve, modify, delay or deny medical treatment recommendations (5 day response deadline) American College Of Environmental Medicine (ACOEM) evidence-based guidelines for medical utilization and certification of treatment for all industrial injuries. 15

What may not be an injury Going and Coming Exacerbation of pre-existing conditions Deviation from employment Recreational activities Altercations (Initial Physical Aggressors) 16

Examples of conditions that permit employer to DENY claim Lack of timely notice of injury Intoxication Horseplay Self-Inflicted Injury Good Faith Personnel Action 17

If claim is DENIED. The Third Party Claims Administrator will: Send a denial letter to the injured employee on or before the 90 th day from date of knowledge of the claim. The letter will clearly outline the reason for the denial and will include appeal rights for the injured employee. Send a copy of the denial will be sent to the Departmental Liaison, as well as the Auditor/Controller s Unit. 18

If claim is ACCEPTED The Third Party Claims Administrator will: Send an acceptance letter to the injured employee. Send a copy of the acceptance to the Departmental Liaison, as well as the Auditor/Controller s Unit. Provide benefits within 14 days. If employee is unable to work, temporary disability payment will be provided accordingly. Medical treatment will be monitored via UR Utilization Review and ACOEM Guidelines. Monitor the claim until the injured employee s condition is deemed permanent and stationary (P&S) or reaches maximum medical improvement (MMI). 19

Workers Compensation Benefits Medical Care Temporary Disability Permanent Disability Supplemental Job Displacement Voucher Death Benefits 20

Medical Benefits All medical treatment necessary to cure or relieve from the effects of the industrial injury Subject to UR and ACOEM Guidelines 21

Limits on Chiropractic, Physical Therapy, and Occupational Therapy Visits Per the Labor Code.. For dates of injury on or after January 1, 2004, the employee is limited to a total of 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits for their injury, unless the claims administrator authorizes additional visits in writing. 22

Temporary Disability (TD) Benefits Paid when employee loses wages and Is unable to do his or her usual job for more than three days with medical disability note from a treating doctor, or Is hospitalized overnight for a work-related injury, or Is released to temporary modified duty and the employer is unable to offer temporary modified work. 23

Supervisor Responsibilities when injured employee is off work After the 3-day waiting period, use W75 or W56 (Public Safety) payroll disability code if employee is off work due to workers compensation claim. Use Code W57 if employee is off of work due to medical appointments (this covers actual and reasonable commute time). Refer to MOU for correct WC pay codes and benefits. 24

Supervisor Responsibilities when injured employee is off work Per department policy, maintain contact with injured employee. Obtain disability or return to work (RTW) slips from injured employee after each appointment to determine work status. Send copies of disability slips to Claims Administrator and departmental/agency liaison. 25

When do TD payments end? When the treating doctor says the employee can return to his or her usual and customary occupation. When the employee returns to modified or alternate work. When the condition is deemed permanent and stationary (P&S) or reaches maximum medical improvement (MMI). 26

Temporary Disability Benefit Per the Labor Code.. Cap Effective 4/19/04 TTD shall not exceed 104 weeks from commencement of first payment of TTD. Effective 1/01/08 TTD shall not exceed 104 weeks within a five year period. Exceptions are Hep A/B, HIV, amputations, severe burns, high velocity eye injuries, chemical burns to both eyes, pulmonary fibrosis, chronic lung disease, which are capped at 240 weeks within 5 year period. 27

County Temporary Modified Work Policy It is the policy of the County of Alameda to make a reasonable effort to provide temporary modified work assignments to employees who may be temporarily unable to perform their usual job assignment due to injury/disability (both industrial and non-industrial), consistent with their work restrictions/limitations. Temporary modified work assignments are not to exceed 90 calendar days per injury/illness. Under extraordinary circumstances, a temporary modified work assignment may be extended up to 210 calendar days on a case-by-case basis. 28

Supervisor s Responsibilities Temporary Modified Duty: Review the employee s medical documentation and temporary work restrictions/ limitations. Create and/or provide a temporary modified work assignment whenever possible. Monitor the employee s temporary modified work assignments and medical documentation following medical appointments. Ensure current Description of Employee s Essential Job Functions (EF5) is on file and forward signed copies to TPA within 60 days of modified work. Ensure employee s time sheet is appropriately coded MOD. 29

Permanent Disability (PD)Benefits Benefit paid to an employee who sustained permanent impairment as a result of the injury. The award is calculated based on the level of disability or disfigurement, age, occupation and consideration for diminished future earning capacity. Note: Employees may be able to continue in their current job and still be eligible for PD benefits. 30

Apportionment of PD Per the Labor Code.. Medical Reports addressing PD must address apportionment. The employer is only liable for the percentage of PD directly caused by the work injury. If the employee received a prior PD award, there is a conclusive presumption that a previous PD exists which can be deducted from current level of disability. 31

For Permanent Modified Job: Determine if permanent modifications can be provided after the employee is determined P&S or condition reaches MMI, based on the permanent restrictions. Modification is appropriate if it allows the employee to perform all the essential functions of the job. Job can be permanently modified or employee can be placed in an appropriate alternate job (alt/mod). If not, agency/department must search for appropriate alternate vacant positions, complete alt/mod form in 30 days and forward to TPA and Risk Management Unit. If job is not available within agency/department, refer injured employee to Human Resources Services for County-wide search. 32

Supplemental Job Displacement Benefits If the employee s treating doctor determines that he or she will never recover completely or be able to return to the same job and working conditions that he or she had before the injury, the employee may be eligible to receive a supplemental job displacement benefit (SJDB). The type of benefit that the employee may receive depends on the date of injury and whether the employer offers the employee a suitable job. 33

Supplemental Job Displacement Benefits Injuries on or after January 1, 2004 A supplemental job displacement benefit is a voucher that promises to help pay for educational retraining or skill enhancement, or both, at state-approved or state accredited schools. The employee can use the voucher to pay for tuition, fees, books, or other expenses required by the school for retraining or skill enhancement. Up to 10 percent of the voucher money may be used to pay for services of a vocational return-to-work counselor, a person who helps injured workers develop their goals and plans for returning to work. 34

Death Benefits Should an employee be killed or sustain job-related injuries resulting in death, his or her dependents may be entitled to statutory death benefits. The benefit amount is determined by the date of injury, the level of dependency and the number of dependents. The family of the deceased is entitled to a burial benefit at a statutory maximum, subject to proof of actual expenses. 35

Type of Settlements Stipulations with Request for Award ( Stips ) Agreement between the claims administrator and employee on how much, when and how long the employee will continue to receive PD payments based on PD determined by their doctor. The claim will remain open for medical care for the agreed injury, as long as care is needed, consistent with ACOEM and UR. Compromise and Release ( C&R ) Agreement between the claims administrator and employee to pay lump sum to cover PD payments that the employee has not received yet and other benefits, including medical care. This is a full and final settlement. NOTE: Both settlements must be approved by the Workers Compensation Appeals Board (WCAB) judge. 36

Things to keep in mind An employee may receive additional compensation if an employer discriminates against an employee who is filing for workers' compensation benefits or because he/she has a workrelated disability under California Labor Code section 132a. Disability discrimination is illegal and prohibited also by the federal Americans with Disabilities Act (ADA) and the California Fair Employment and Housing Act (FEHA). Serious and Willful: Labor Code section 4551 and 4553 provide that an employee or employer can recover additional compensation if they can prove serious and willful liability based upon a violation of a safety order of the Division of Occupational Safety and Health. 37

Workers Compensation Fraud Insurance Code 1871.4 Making knowingly false or fraudulent material representation for the purpose of obtaining or denying workers compensation. Help us prevent and/or stop fraud by calling this number to report suspected workers compensation fraud: 1-866-368-3720 38

Some Examples of Fraud: Filing a claim for an injury that did not occur on or has no relation to the job. Knowingly misrepresenting physical condition to obtain workers compensation benefits. Working another unreported job while receiving TD workers compensation benefits from the County of Alameda or a job with duties beyond restrictions. An attorney or health care provider assisting in fraudulent schemes, participating in double billing or intentionally billing for services not provided or unwarranted. Punishable with a fine up to $150,000.00 and/or 1-5 years in prison 39

Preventing and Managing Injuries/Illnesses Train employees on workplace safety Encourage wellness and fitness activity Utilize ergonomic evaluation/equipment Update injury & illness prevention program Return injured employee to work as soon as medically possible 40

Online resources County RMU Website: http://www.acgov.org/cao/rmu/programs/workers_comp Workers Compensation Websites www.dir.ca.gov: This link will take you directly to the Department of Industrial Relations, Division of Workers Compensation. It provides helpful information regarding labor law, Cal/OSHA, and Workers Compensation. www.insurance.ca.gov: This link will take you directly to the California Department of Insurance. It provides helpful information for consumers, seniors, agents and brokers, insurers, and fraud overview. 41

County of Alameda Risk Management Workers Compensation Contact Information For general Workers Compensation claims questions, or to schedule a claim review with our Third Party Administrator, contact Beth Van Arkel, Workers Compensation Administrator (510) 272-6045 or tie line 2-6045 For additional training or questions regarding modified work, contact Maria Songco-Daluz, Risk Coordinator (510) 272-3646 or tie line 2-3646 To request a preventive ergonomic assessment, e-mail ergolab@acgov.org 42

County of Alameda Third Party Administrator Sedgwick CMS Office P.O. Box 2065, Oakland, CA 94604 Toll Free Number: 1(800)225-2998 QIC 25101 For new claims only, fax to (510) 302-3286 For all other claims-related correspondence, fax to (510) 302-3269 - QIC 25101 43