Each state administers its own workers’ compensation program and has a statute that governs workers’ compensation, so coverage differs from state to state. Still, all states provide two types of workers’ compensation benefits. One pays the employee’s medical expenses that result from the work-related injury, and the other compensates the employee for lost wages while he or she is unable to return to work. Workers’ compensation pays for all reasonable and necessary medical expenses resulting from the work related injury. The Workers Compensation Claim process starts when a worker is injured on-the- job, and the employer is informed, the employer must inform the insurance company and state workers compensation about the incident in writing, after the employer has reported the incident he/she will receive notification to take the injury party to a doctor that provide medical care for the injury or illness.
The healthcare provider is chosen by the employer or insurance carrier, if the employee for any reason refused to see the doctor chosen, there are chances the claim will not be paid, and the employee must find first aid or care for their injuries as-soon-as-possible. Everyone involved have a responsibility to make sure all the necessary steps are followed in filing a claim to ensure that the injured employee get care, and the employer is covered from all mishaps just in case something goes wrong with the workers compensation claim.
When a claim is filed and accepted by the workers compensation committee which authorizes benefit payments to be paid by the employer, within thirty days the claim an award is issued or the claim is placed before a hearing to be contested or further reviewed, the next step is the benefit phase for accepted claims, this involved medical treatment and pay compensation for loss of pay. The benefits could be paid voluntarily or through entitlement contest. The workers will receive maximum medical benefits for their injuries.
If a death was involved the benefits will cover permanency for the survivor of the worker. The employee is responsible for abiding by the rules and regulations of the job, if a worker is not complying with the rules and regulations are not entitled to workers compensation. The employer is responsible for filing the first report of the injury; the employer must make sure that all the information on the claim is correct and accurate to what happened, copies are made one goes to the injured person, and another one is kept for the company’s records and the other for the filing of the work related injury. The physician has a role in the claim process, the percentage of disability and return date back to work is provide by the attending physicians, the injured worker must follow the physician’s medical orders because the physicians must do a progress report, and the responsibility of submitting a plan of how much it will cost to treat the injured worker.
The insurance carrier determine Admission of Liability or notice of contest, the determination to pay the claim or deny the claim, everyone involved must do their part to ensure the compliance is meet by the insurance carrier. The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of individually identifiable health information, HIPPA applies to group health plans, health care clearing houses, and health care providers, it does not apply to workers compensation, when a worker’s compensation claim is filed the privilege of privacy have been waived in regard to the claim, employers can contact the health care providers with any question regarding the claim.
The implications of unrestricted access to a patient’s medical records is sometimes confusing to doctors when it comes to concerning with HIPAA law, which is to protect the privacy but when it comes to dealing with works compensation doctors are allowed to give out information, some doctors are scared to give out information concerning a patient information because of the severe penalties for violations, doctors are not require to get HIPAA authorization before talking to anyone concerning a patient that has filed a worker’s compensation claim, Under privacy rules a patient does not have the right to suggest that his/her physicians not give out information about a worker’s compensation claim.
A physician has the right to discuss the Patient Protected Health Information (PHI) with everyone that is involved in the claim process, the reason is because of the requirement of the law about workers compensation, claims adjusters and employers have a right to have access to a worker’s compensation file that is unrestricted (Valerius, Bayes & Seggern 2008).
PP. 425-427 in CH.13 of Medical Insurance