First Report of Injury Accuracy Critical for Workers Comp Success

Delegating First Report of Injury Can Create Problems

 

Risk managers and workers’ compensation managers normally delegate the job of filling out the First Report of Injury form (also known in some states as the Employer’s First Report). Delegation of the First Report of Injury to someone who is not extremely careful create numerous problems. All the information on the First Report of Injury needs to be checked carefully before it is submitted to the claims office and to the state Workers’ Compensation Commission / Department of Labor / Industrial Commission / etc. For this article we will use Workers’ Compensation Commission (WCC) for all the states.

 

The First Report of Injury form is usually given the number 1 in most states, whether it is known as the WC-1, DWC-1, or other nomenclature. The reason the form is given numeral 1 is because normally it is the first form for both the WCC and the claims office. The information and data used by both the WCC and the claims office in setting up their files is taken from the First Report of Injury. Little errors on the First Report of Injury are copied and can create havoc.

 

 

Ensure Important Details are Correct

 

Name Spelled Correctly

The spelling of the employee’s name should be checked. If the last name is misspelled by the employer’s representative completing the First Report of Injury, the WCC will copy it verbatim. When the WCC receives medical information or other state forms which they are unable to match to an existing claim, the WCC will inquire as to why the claim has not been reported, as they could not find the work comp claim in their database.

 

 

 

Correct Social Security Number

An employer should never submit a First Report of Injury without the correct social security number (SS#). Too often when the SS# is not readily available, the employer’s representative will use a fake SS# such as 123-45-6789 or 000-00-0000 or 999-99-9999. This may get the First Report of Injury off the desk of the employer’s representative, but it creates issues for the employer, the WCC and the claims office. For the employer, it can mess up your loss run accuracy. The WCC will being call the employer and/or the claims office for the correct SS#. The claims office can submit the Insurance Services Office (ISO) inquiry with the fake SS#, but the likelihood of identifying previous insurance claims by the injured employee is greatly reduced when the SS# is not accurate.

 

 

Correct Date of Injury

When the date of injury is incorrect problems occur. In most workers’ compensation claims, the date of injury is also the date of the first medical treatment. Most claim management computer systems are programmed to kick out medical bills that occur before the date of injury. For example: an incorrect date of injury of 3-3-13 is entered on the First Report of Injury while the correct date of injury is 3-2-13. The medical bills from 3-2-13 will get denied because, to the computer system, they occurred before the date of injury. This results in phone calls from the medical provider(s) and the claims office trying to determine the correct date of injury.

 

 

Proper Wage Information

When the wage information on the First Report of Injury is incorrect, it will create problems, especially if the employee is represented by an attorney. Too often the employer’s representative will take the easy way out rather than contacting the payroll department for the correct wage information. When the employer’s representative completes the First Report of Injury reflecting the employee works 5 days a week, 8 hours per day, at the standard hourly rate for the work the employee normally does, without verifying with the payroll department, problems arise. For example, on a 40 hour week with a position that pays $10.00 per hour, $400.00 is entered as the weekly wage. But in reality, work has been slow; the employee has been absent a lot and has only averaged 32 hours per week. In this situation, the employee’s attorney often will request a hearing trying to compel the payment of disability benefits based on the higher payroll information entered on the First Report of Injury. This will force the claims adjuster to spent time and legal fees proving the correct earnings information.

 

 

Proper Type of Injury & Body Part Affected

The importance of properly entering on the First Report of Injury the type of injury and the body part affected cannot be overstated. One of the first things an attorney for the employee will do is check the First Report of Injury for the type of injury and the body part. If this information is missing, your represented employee’s injuries will expand dramatically. Neck and back injuries that you did not know the employee had on the date of injury will suddenly appear. The employee’s pre-existing medical problems will be severely aggravated. The additional medical treatment and extended time off work can be very costly when the type of injury and body part is not completed properly.

 

 

Double Check First Report of Injury Prior to Submission

Any incorrect or incomplete information on the First Report of Injury can result in problems. A lot of the problems created by wrong information can be corrected with a few phone calls or the resubmission of the First Report of Injury with the correct information. However, this is a waste of time for all the parties involved. Plus, when the First Report of Injury is inaccurate or incomplete, it can often be exploited by the employee’s attorney. To make the job easier for everyone related to the workers’ compensation claim, be sure your representative who completes the First Report of Injury checks it twice to be sure it is totally accurate.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 


Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional about workers comp issues.

The Employers Secret to Workers Comp Defense Lies in these Three Quotes

 

Three quotations are all an employer needs to understand handling difficult comp claims. Two are actual quotes, but the third – and best – was made up and appeared in a 1917 newspaper story.
 
Three Quotes:
 
1. “Justice is truth in action”, written by Benjamin Disraeli in a novel.
 
2. “Justice delayed is justice denied”, an old legal maxim.
 
3. “Git thar the fustest with the mostest”, supposedly, but actually never, said by Confederate Gen. Nathan Bedford Forrest. Winston Churchill, however, called it the most delightful summary of military tactics ever spoken
 
So, to get the best justice, an employer needs “truth”. To get “truth” too late is to get no justice at all.  Therefore, get truth as early as possible and be “the fustest with the mostest”. Even if  Forrest never said it, Churchill endorsed it.
 
 
Be the First with the Most
 
But how does an employer be the first with the most? The only way that can happen is for an employer to be prepared to locate, retrieve and forward a portion of the large amount of information available to an employer. Even if an employer does not possess actual documents, an employer has clues as to where those documents might be.
 
 
Write Outline Summary, Attach to First Report of Injury
 
The best advice for an employer is to write a one, possibly two, page outline of what documents might contain information about past, relevant events, who might have them, and where they might be, even if not with the employer. Forward it to the carrier, preferably attached to the First Report Of Injury. Then, follow up with a call to make sure that the outline has been received, noticed, read and acted upon.
 
Attaching the outline to a First Report of Injury insures that the information will be “the first”, but will it be “the most”? Almost certainly, it will. Initial claims handling is mostly a matter of taking care of the first medical reports and bills. Collecting the information needed for long term results waits. And whatever waits cannot be in action and is, therefore, delayed. And, finally, will never be the first or the most.
 
 
 

Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Every Workers Comp Claim Has a FIRST WEEK … Learn Why It Is So Important

EVERY CLAIM HAS A FIRST WEEK. Right!
 
We all know that, it is obvious. What else would you call the seven days which follow an accident? And how, barring the end of the world, would you not have a first week? But that is not the message of this piece.
 
 
The first week following an accident is a one-time period for opportunity. A diligent employer can, in those first seven days, shape the outcome of a claim so that all (in this case, the employer and employee) will benefit. The “losers” will be those who stand to gain from inefficiency, which is to say, everyone else in the claims process. [WCx]
 
 
Why is the first week so important? The law requires some things to be done rather quickly (filing an employer’s report of injury) but most can surely wait until the carrier does them – can’t they? The technical answer is, “Yes.” The smart answer is, “No!”
 
 
Every claim does have a first week- but none have two of them. Once the first week passes without action it can never be regained – and the first week is exclusively the employer’s. A carrier cannot effectively get started defending a claim until several weeks passes from when it is notified.
 
 
What should the employer do in this period? Oversee the care of the employee and gather facts. The first is not optional – at least not in NY.
 
 
 Most people who work in the comp field in NY are surprised to learn that the comp law places an affirmative responsibility on the part of the EMPLOYER (no one else is mentioned) to see that an injured employee receives proper medical care.  That does not mean selecting a treating doctor (although that was actually done in the first decades of the comp law), but it does mean that the employer should not be passive if the employee is obviously not getting the treatment needed.
 
 
The other responsibility which should be attended to by the employer is gathering a forwarding (to the Board, the carrier, the treating doctor and the worker) information and documents which will be needed (payroll, details of accident) or which might be needed (prior injuries, claims, employers, medical plans, periods of significant absence, etc.).
 
 
The last, documents which might be needed, puzzles many employers. If the information is not requested, why would it ever be needed? The answer is that if others do not know the information exists – why would they request it? True, they should ask what other information exists – but in the real world they usually do not. Nothing will increase an x-mod faster than the useful information which remains silent and uninvited, sitting in a file cabinet drawer (or in cyberspace).
 
 
Finally, there is the therapeutic aspect of purposeful activity. A worker, and the worker’s family, is all too frequently struggling through a morass of silence and indifference during the first weeks. The person closest to them, the employer, seems to be uninvolved in the claim. Many employers are under the impression that they are REQUIRED to be out of the loop. “The carrier has to do that.” In truth, the comp law mentions the employer frequently and the carrier hardly at all – except as surety for payment of awards. [WCx]
 
 
In short, it is difficult for an employer to be over involved in a claim. Or over concerned about the welfare of an employee. And the best time to become involved and concerned is – the first week.
 
Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net


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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Shooting Blanks Can Be Deadly For Employer and All Bystanders

Nearly all problems on a workers comp claim are traceable to the first report of injury (FROI). The first report (C-2 in NY) is one of two or three documents starting a claim. Other forms are the worker’s application for benefits (C-3 in NY) or an initial medical report sent to the workers compensation board.
 
 
However, the employer’s first report of injure (C-2) is determines, more than anything else, what the future course of the claim will be like, such as:
 

1.     Will there be, literally, a dozen or more unnecessary hearings?

2.     Will there be a trial over non-existent defenses?

3.     Will real defenses go unnoticed until far too late, or never be noticed at all?

4.     Will reserves be unnecessarily high?

5.     Will proper payments be too late? (WCxKit)

6.     Will the wrong witnesses be called on the wrong issues?

 
If these questions sound like unchecked chaos, it is really very close to an average performance than it is to a rare failure. Why?
 
 
Persons routinely review first reports coming in from a variety of employers know the answer: blank boxes. Or boxes marked “unknown” in answer to relevant questions. Questions an employer, with a bit of diligence, can answer; or explain why an answer is not possible.
 
 
The remedy to the above is a phone call and a document. The person required to complete the first report of injury is a witness to the incident and does not have the necessary knowledge to answer all, or even most, of the questions on a first report. If the person is a witness, usually a foreman, it’s unlikely answers to such questions as the workers compensation insurance policy number, date of coverage, etc., are known.
 
 
As a result, pressure to get a report, any report, in quickly inevitably leads to the deadly barrage of blanks. In time, the blanks metamorphose into land mines exploding unexpectedly at hearings months or years in the future.
 
 
The first measure to take when blank boxes are encountered is a phone call. People able to provide quick answers to transform the blank box into a source of useful information are within the sound range of a ringing telephone. Therefore, make the correct phone ring and get the answer.
 
 
The second measure involves some pieces of paper and a stapler. The first report of injury form may have nearly sixty boxes to complete, with little space for complicated answers. Therefore, let documents answer the questions and, to assure their presence, staple them to the report form. And put the best of all answers — “see attached”— into the appropriate box.
 
 
Be pro-active about dissemination of information. Send a copy to the carrier, of course, but also to the workers compensation board, the worker and the worker’s attorney. Sooner or later, all will need the information so make it sooner. (WCxKit)
 
 
Documents have certain advantages over witnesses, the chief being that they never change their stories. Share them with others. Ask Ted who should be copied on these documents – you'd be suprised.
 
Remember, if the employer leaves boxes blank the worker’s attorney will be happy to volunteer the answers and it’s rare the employer will agree with those conclusions.
 
 
Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, New York and an expert in providing training to employers in basic reporting and investigation of workers compensation claims. His NY FROI Training Program and Coaching can help employers do it right the first time. He also is a frequent writer and speaker, and has represented employers in the areas of workers compensation, Social Security disability, employee disability plans, and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100.
 
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@ReduceYourWorkersComp.com.

What You Need to Know About Employers First Report of Injury (FROI)

A recent item in the news about the Missouri Attorney General’s office levying fines totaling over $100,000 against two national third party administrators (TPA) for the failure to file the Report of Injury form on some workers compensation claims has caught the attention of employers,  insurers and TPAs alike.

 

 

Almost all jurisdictions require that some or all workers compensation claims be reported to the appropriate state workers compensation board, industrial commission or other state supervisory office. The name of the reporting form varies, but most states refer to it as the Employer’s First Report of Injury (FROI). The requirements as to which workers compensation claims are reported to the state vary. Some states, for example – Colorado, require every work comp claim to be reported, while other states only require indemnity claims to be reported. Missouri requires every workers compensation claim, except those claims involving first aid with no further medical care, be reported. (WCxKit)

 

 

Each state has its own version of the Employer’s First Report of Injury form (with varying names), which can usually be found on the states website. Each state also assigns their own form number to the Employers First Report of Injury form. In some states it is known as the E-1 or the WC-1 or the 1A. While most states will still accept a paper copy of the Employer’s First Report of Injury, all the states are now encouraging the electronic filing of the Employer’s First Report of Injury form.

 

 

The states also vary in who is responsible for filing the Employer’s First Report of Injury. In most states, it is the employers responsibility to file the Employer’s First Report of Injury. In Missouri, it is called the Report of Injury, where it is the responsibility of the insurer or the TPA to file the Report of Injury with the state after the employer has reported the claim to them. In the states where it is the employer’s responsibility to complete the Employer’s First Report of Injury, most of those states will allow or even require the employer to send the Employer’s First Report of Injury form to the insurer or TPA, and allow or require the insurer or TPA to submit the form to the state.

 

 

The information the employer/insurer/TPA places on the Employer’s First Report of Injury form is fairly consistent from state to state. The information needed to report the claim to the state will include:

 

  1. The employer’s name and address
  2. The employer’s federal tax ID number
  3. The nature of the employer’s business
  4. The employer’s insurance company name/self insurer name and policy number
  5. The insurance company’s claim number or the TPAs claim number
  6. The insurance company’s address and phone number, or the TPAs address and phone number
  7. The employee’s name and address
  8. The employee’s social security number, or green card number, or employment visa number
  9. The employee’s date of birth
  10. The employee’s occupation
  11. The employee’s telephone number
  12. The date of the injury or illness
  13. The machine, tool or object causing the injury
  14. The nature of the injury or illness

15   .The body part(s) affected

  1. A description of the occurrence
  2. The medical providers name and address
  3. If the accident was fatal, the employees martial status

 

 

Some states also require the Employer’s First Report of Injury to contain income benefit information including:

 

  1. Date disability / inability to work began
  2. Employee’s average weekly wage
  3. Employee’s weekly benefit
  4. Date of first indemnity payment
  5. Type of first indemnity payment temporary total disability, temporary partial disability, permanent partial disability

 

 

Upon receipt of the Employer’s First Report of Injury, the state supervisory office will issue their own board claim number or jurisdiction claim number or other identifying number to track the claim in their own system. Some states require the insurer or TPA to send a copy of the Employer’s First Report of Injury form to the employee, while other states will send the employee their own information packet. (WCxKit)

 

 

Almost every jurisdiction has a penalty or fine that can be imposed for the failure to file the Employer’s First Report of Injury form. The purpose of the penalty or fine is to encourage employers to comply with the law on reporting claims to the state, not to collect revenue from employers, insurers or TPAs.    However, as the Missouri cases reflect, the states can (and should) enforce compliance with the reporting requirements. Every employer should take time to be familiar with the Employer’s First Report of Injury form and know the law within their state as to whom and when they should submit the Employer’s First Report of Injury form.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.  See www.LowerWC.com for more information.  RShafer@ReduceYourWorkersComp.com .

 

WC IQ TEST:  http://www.workerscompkit.com/intro/

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SUBSCRIBE: 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact 
Info@ReduceYourWorkersComp.com.

 

Immediate Claim Reporting Advantages

Gone are the days of mailing the Employer’s First Report of an accident to the insurer’s claims office. A three or four day delay in starting the claim due to the mail service is not an acceptable claims handling practice like it was a couple of decades ago. Today, with the internet, the claims report will be in the claims office within seconds of it being sent by the employer.
With electronic reporting of claims of claims available 24 hours a day, 7 days a week, 365 days a year, the employer can submit the claim at any time. Therefore, the best time for the employer to report an injury claim or a reported occupational illness is immediately upon learning of the event. Fast, accurate reporting of the claim benefits both the employer and the employee.
When the injury occurs, the employer’s first and foremost duty is obtain the appropriate medical care for the employee. It’s the employer operates in a jurisdiction where the employer selects the medical provider, the employee should be directed to the nearest medical facility appropriate for the injury. If the employer is in a jurisdiction where the employee can select their own medical provider, a list of recommended medical providers should be provided to the employee to select from. When the employer shows immediate concern about the injury to the employee, a higher level of communication about the injury throughout the claim will be established.
There are several benefits to reporting the claim immediately. They include:
1.     It lowers the cost of the claim – studies have shown the faster the claim is reported, the lower the overall cost of the claim.
2.     A study by Firemen’s Fund reported a 3-day delay in reporting a claim added an average of 16% to the medical cost and 38% to the indemnity cost, and increased attorney involvement by 50%.
3.      A study by Hartford Insurance Company showed a week’s delay in reporting the work comp claim increased the overall claim cost by 10%, and a month’s delay in reporting the work comp claim increased the settlement cost of the claim by 48%. Furthermore, the Hartford study showed the longer the delay in reporting the claim, the higher the probability of litigation.
4.     A study by the National Council on Compensation Insurance found that litigated claims cost 40% more to settle than non-litigated claims.
5.     The claims office cannot accomplish anything until the claim is reported – the claims office can get started with their investigation immediately when the claim is reported immediately. (Your claim handling agreement with the insurer or the third party administrator should specify all employees will be contacted the same day the claim is reported to the claims office).
6.     The employee, the supervisor and any witness memories are fresh and important details are not forgotten.
7.     Witnesses to the accident are available.
8.     If an inspection of the accident scene is needed, the accident scene is more likely to be unchanged than it would be later.
9.     If the injury involves equipment failure or machinery failure, expert assistance can be used to establish and maintain subrogation rights.
10.The immediate reporting of the claim allows the adjuster and the nurse case manager the opportunity to take prompt cost reduction steps.
11.The employee can receive the right medical care by having the managed care provider involved in the claim from the start. Trying to change the medical treatment plan of a doctor after the doctor has been treating the employee can result in a disruption of care, confusion or even attorney involvement.
12.It shows the employee you care about the employee’s well being.
13.It allows for the establishment of a modified duty return work process before the employee can contemplate how long he/she can be off work.
14.It perpetuates the employee’s return to a normal lifestyle of working a regular schedule.
15.It minimizes the interruption of your business.
 
The immediate reporting of claims allows the adjuster to investigate and validate the compensability of all claims. It allows for immediate medical intervention while providing the appropriate medical care. The immediate reporting of claims also protects the insurers right of recovery from any responsible third party. Also, the immediate reporting of claims puts the employer and the claims office in charge of the claim, preventing a medical provider or plaintiff’s attorney from usurping the direction and control of the claim.
Every department manager and every supervisor should be trained to immediately report all claims to the employer’s work comp claims coordinator. If the employer does not have a work comp claims coordinator, the supervisor or manager for the employer should immediately complete the Employer’s First Report of Injury and electronically submit it to the claims office. When the claim is severe, the claims coordinator or department supervisor should telephone the claims office with the information on the claim. To insure compliance with the immediate reporting requirements, the timely reporting of work related injury should be a component of the supervisor’s performance evaluation and salary increase. (WCxKit)
The immediate reporting of claims will reduce the medical cost, will reduce the indemnity payments, will reduce the employees time away from work, will lower the claim administration cost and reduce the possibility of attorney involvement. The immediate reporting of claims is an essential step every employer should take to control workers’ compensation cost.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.
Contact: 
RShafer@ReduceYourWorkersComp.com or 860-553-6604.

 
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
 
WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

HIPAA, Workers Compensation and First Report of Injury

An area where a lot of employers, workers compensation claim adjusters and even some lawyers get confused is the requirements of HIPAA – the Health Insurance Portability and Availability Act of 1996, which became fully functional in 2003. The law was written to protect the personal health information of individuals, and to keep the personal information as private as possible.

 

Like most federal regulations, it was written in code. Instead of saying the HIPAA law applies to doctors, hospitals, health care clinics, and other health service providers, the HIPAA law refers to “covered entities.” An employer is not a “covered entity” unless the employer is also a provider of medical services, and then HIPAA does not apply to medical information in your employment records.(WCxKit)

 

The HIPAA law uses another two code phrase a lot – “personally-identifiable health information” (PHI), and “protected health information” (PHI)  both meaning the same thing. [Yes, two phrases meaning the same thing, both using the same acronym – PHI].   By PHI the law is referring to:

 

  1. Health care claim forms
  2. Health claim attachments
  3. Health care encounter information (like the doctor’s or nurse’s notes in the doctor’s file)
  4. Eligibility for a health plan
  5. Enrollment in medical insurance – like Blue Cross or Aetna
  6. Health plan premiums
  7. Health care payments
  8. Dis-enrollment from medical insurance
  9. Health care claim status

10.Coordination of health care benefits

11.Medical referral authorizations and certifications

12.Last but not least – First Report of Injury

 

 

All the PHIs were referring to health insurance until the last one listed – the First Report of Injury which is the most often used workers’ compensation form. Now this is where confusion about HIPAA arises for the employer. The First Report of Injury form you complete when the employee has a work comp claim is PHI when it is in the possession of the medical service provider. When it is in the employer’s workers compensation file, it is not PHI and not subject to HIPAA. (It may be subject to state privacy laws – more on that later).

 

The same guidelines for the employer’s handling of the First Report of Injury apply to the work comp adjuster’s handling of the First Report of Injury. When the adjuster requests the medical records for an injured employee, the medical provider can provide all of the PHIs listed above and not be in violation of HIPAA. The HIPAA law specifically excludes workers compensation from its far reaching tentacles.

 

Workers compensation insurance companies, employers who are self-insured for workers compensation, third party administrators, medical case managers and workers compensation boards/industrial commissions are allowedby HIPAA to obtain all necessary medical information for the purpose of processing workers compensation claims. State laws governing the obtaining of medical information for work comp claim handling still apply. As the state laws on workers compensation can vary tremendously from state to state, the employer needs to know and understand the work comp laws and privacy laws of the states where they do business.

 

Often when the employee’s attorney does not want the work comp adjuster to know about the employee’s preexisting double laminectomy, or some other preexisting medical issue, the attorney will try to throw-up a smoke screen telling the adjuster t they cannot have the employee’s pre-injury medical records due to HIPAA. This is totally incorrect. HIPPA specifically allows in Title 45 of the Code for Federal Regulations (CFR) for disclosure of the employee’s pre-injury medical history:

 

  1. If the disclosure is authorized and to the extent necessary to comply with laws relating to workers’ compensation………(to) provide benefits for work related injuries or illness {this info is in the statute – 45 C.F.R. Paragraph 164.512 (1)}
  2. If the disclosure is required by state law, the disclosure is limited to whatever the law requires {45 C.F.R. Paragraph 164.512(a)}
  3. If the disclosure is for the purpose of obtaining payment for health care provided to the employee { 45 C.F.R. Paragraph 164.502(a)(1)(ii)}

 

 

In most states the notification to the medical provider that the information is being requested for the purpose of processing a workers compensation claim is all the authorization needed for the medical provider to send the information to the work comp adjuster.   In the few states requiringthe adjuster to obtain a medical authorization before obtaining the medical information from the medical provider, it is the state law that requires the medical authorization, not HIPAA.

 

In the situation noted above where the employee’s attorney is trying to block the adjuster from having the information about the employee’s preexisting medical condition, HIPPA does not stand in the way. The adjuster in most states will still need the medical authorization for medical records prior to the date of the employee’s injury, but the adjuster can petition the work comp board to require the employee to provide the medical authorization if it is not freely provided. (WCxKit)

 

The employer should understand that HIPAA does not hinder the processing of work comp claims. Some states have passed their own versions of medical privacy laws that are more restrictive than HIPAA. Also, some of the states have other privacy laws limiting the information you can disclose about an employee. If you have any question about what your state requires, please consult with an employment law attorney. If you have any questions about HIPAA and its relationship with workers’ compensation, please contact us.Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.
Contact:  RShafer@ReduceYourWorkersComp.com or 860-553-6604.


WC IQ TEST:  
http://www.workerscompkit.com/intro/

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

 

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Employer Is MIA – Missing In Action – in the Work Comp Process

Tips from Ted
There is mounting interest in services for first week after accident report. As Rebecca Shafer has projected, as we move toward 2020, there will be more and more importance given to the first few hours after an accident. The first hour is the most critical, according to Shafer. The reason is obvious. Lag time with carriers is now over one month, more than enough time for a defense to collapse even before it's mounted.
 Let me just summarize the way it was in the first decade after the workers comp law passed in New York:
1.     It was assumed the employer would make the payments and later seek reimbursement from the carrier. That happened.
2.     It was assumed hearings would be rare and the carrier would not attend. A hearing would be an informal meeting with the employer and worker talking it out before an officer.
3.     Medical testimony would be rare. Only traumatic workplace injuries were covered, only dangerous, heavy occupations were covered. Medical issues in the reported cases involved trying to connect non-traumatic conditions to an accident.
All that changed. Carriers insisted their investment was best protected by taking over the defense, although nothing in the law says they can do that. (WCxKit)
Hearings became the universal rule, not the exception. Attorneys looked for every excuse for more hearings and the system drifted toward the universal tar pit. Lawyers became essential for the worker. Unions acquired power by backing certain firms and feeding the work.
What changed everything? Taking the proactive role of the employer out of the claim process and giving it to a company that, quite literally, made its profit from the "float,” i.e., delay, delay, delay. Everyone associated with defense made their living the same way. Lawyers, doctors, investigators, rehab, agents, brokers. (WCxKit)
The employer was no longer part of the process.
I am presently involved with two efforts to bring rapid response by the employer to the process.
Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers' compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100.
 
Join WC Group: 
http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
WC Calculator:  http://www.LowerWC.com/calculator.php
TD Calculator:  http://www.LowerWC.com/transitional-duty-cost-calculator.php 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues.
  
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
 Info@ReduceYourWorkersComp.com

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