2014 governor’s occupational safety & health conference workers compensation 101 for safety...

2014 Governor’s Occupational Safety & Health Conference

Workers Compensation 101 for Safety Professionals

Presenters•Scott G. Weiant, PA Bureau of Workers’ Compensation

•Tammy Laughman, PA Bureau of Workers’ Compensation, Claims Management Division

•Judge David Cicola, Workers’ Compensation Office of Adjudication

Session Highlights

2014 Governor’s Occupational Safety & Health Conference

• Workers’ Compensation Automation and Integration System (WCAIS) Employer / Claimant use.

• PA Workers’ Compensation Claims Process

• PA Workers’ Compensation Adjudication basic information

• Open Forum


What is WCAIS?

•Workers' Compensation Automation and Integration System or "WCAIS", the electronic system integrates the program areas of the Bureau of Workers' Compensation (BWC), Workers' Compensation Office of Adjudication (WCOA), and the Workers' Compensation Appeal Board (WCAB).

•The WCAIS BWC, and WCOA system went live September 9, 2013 . The workers' compensation community now has access to all workers' compensation matters, including claims, disputes and appeal information 24/7.

Workers’ Compensation Services Management Enabled by WCAIS

Online Registration

Dashboard Management

Navigation

Electronic Submittal of DocumentsSearch and

view Claims

Direct online access to Helpline

Users:•PA Bureau of Workers’ Compensation, Insurers and the rest of the Workers’ Compensation Community

Injured Worker (Claimant)

Healthcare Providers and UROs/PROs

WCAIS

Attorneys

Self-Insured Employers, Insurers and TPAs

PA Bureau of Workers’ Compensation, Office of Adjudication, and Appeal Board.

Employers

Workers’ Compensation Automation and Integration System

Register


View Claim information


The Claim Summary screen is a one stop place for Interested Parties to view all claim

information, and any related Disputes, Appeals, Healthcare Services requests,

payments, SFR Applications, EDI transaction information, and documents

and correspondences for the Claim


View Dispute Summary


The Dispute Summary provides details to a selected Dispute on a Claim. The user

can view submitted Petitions and file Answers. The user can view information for

past and upcoming Hearings and Mediations, view and submit requests, view and submit

exhibits, view the list of witnesses, view the brief schedule set by the Judge and submit a brief,

view circulated Decisions and view any submitted documents or correspondence related to

the Dispute.


To register and use WCAIS, go to wcais.pa.gov

For more information about WCAIS:

1. Visit the project website at

www.dli.state.pa.us/WCAIS

2. Email the Project team at

[email protected]


PA Workers’ Compensation Claims Process


What is workers' compensation?

•In 1915, the Pennsylvania Legislature enacted the Pennsylvania Workmen’s (Workers’) Compensation Act (act). The workers’ compensation system protects employees and employers. Employees receive medical treatment and are compensated for lost wages associated with work-related injuries and disease, and employers provide for the cost of such coverage while being protected from direct lawsuits by employees.

•If you sustain a job injury or a work-related illness, the Pennsylvania Workers' Compensation Act (Act) provides for medical expenses and, in the event the claimant is unable to work, wage-loss compensation benefits until able to go back to work. Additionally, death benefits for work-related deaths are paid to the claimant’s dependent survivors.

•Benefits are paid by private insurance companies (also includes third-party administrators) or the State Workers' Insurance Fund (a state-run workers' compensation insurance carrier) or self-insured employers.


When must a workers’ compensation claim be filed in PA?

– Employers are required to immediately report all employee injuries to their insurer or, if self-insured, to report them to the person responsible for management of the employer’s workers’ compensation program. Employers are also required to file a First Report of Injury (formerly the Employer’s Report of Occupational Injury or Disease) with the bureau within 48 hours for every injury resulting in death, and within seven days for all other injuries which result in disability lasting more than a day, shift or turn of work.

– The acceptance or denial of a claim must be submitted to both the bureau and the employee no later than 21 days after the employer has notice or knowledge of the employee’s disability.


Claim submission to the bureau• Claim information is submitted via the Electronic Data Interchange (EDI), which is

an electronic way of sending workers’ compensation claim information. • EDI increases quality and timeliness and is used to report all claim events.


Claims Forms: Common Issues

Claims Forms: Common Issues

•Missing signatures on LIBC forms. If requested on the form, signatures are mandatory. Ensure that the form is signed by all parties.

•Missing First Report of Injury (FROI). BWC is returning an increased number of forms. Two primary reasons for the returns are:

– 1. The FROI submission creates the claim; without a claim there is no method for BWC to otherwise retain or docket forms outside of WCAIS. The FROI must be submitted electronically before other documents are submitted, such as the Temporary Notice of Compensation Payable, the Notice of Compensation Payable, etc. Forms received prior to the initial FROI transaction cannot be uploaded to WCAIS, as there is no claim established in the system to which the forms can be attached. These forms, therefore, will be returned.

– To prevent your form from being returned to you, submit the FROI 00 or FROI 04 prior to submitting the LIBC form, and make certain that the data on the form matches the data you transmitted in the EDI transaction. For more information on EDI, WCAIS or LIBC forms, refer to the Department of Labor & Industry website.

– 2. The EDI transaction and form have different match data elements. Match data required to attach an LIBC form to a claim includes the first three letters of claimant’s first name, SSN and date of injury. All three must match in order for BWC to attach the form to the claim. (If the LIBC form has the incorrect data, please have your carrier submit a corrected form to BWC. If the EDI transaction has the incorrect data, please submit a FROI 02 to correct the claim in WCAIS.)


Top 4 injury types for 2012

• Sprains & Strains – 43.9%• Other – 15.7%• Contusion, Crushing & Bruise – 15.2%• Cut, Laceration & Puncture – 11.1%

* Total cases reported for the year were 85,117


Top 4 body parts affected for 2012

• Upper Extremities – 33.5%

(shoulders, arms, wrists, hands, and fingers)• Lower Extremities – 23.5%

(hips, legs, knees, ankles, feet, and toes)• Trunk– 22%• Head– 8.9%


Top 4 causes of injuries for 2012

• Overexertion– 29.9%• Struck by – 17.2%• Fall on same level– 11%• Bodily reaction– 10.7%


Age information for 2012 injuries• Workers in the 50-54 year age group sustained the greatest number of injuries in 2012.• The largest number of fatalities was also reported in this same age group.• This age group had 10,385 cases, which represented 12.2% of the total reported.• The median age of injured workers in 2012 was 43.5.


Do I have to go to the company doctor when injured at work?

•Under Section 306(f.1)(1)(i) of the Pennsylvania Workman's Comp Act, an injured worker has to treat with a "company doctor" for 90 days from the first visit only if the employer:

•Creates a list of at least six designated health care providers, •Provides written notification of the employee's rights and duties to the employee, •Obtains the employee's written acknowledgment that he or she has been informed of these rights and duties. •If an employer fails to do this, an injured worker can receive treatment from any doctor or provider.


Choice of Health Care Provider

•Claimants’ are free to choose their own health care provider to treat their work injury unless the employer accepts the claim and has posted in the workplace a list of six or more physicians or health care providers. You are required to visit a provider on the list for initial treatment. Claimants’ are to continue treatment with that provider or another on the list for a period of 90 days following the first visit. Claimants’ may see any provider on the list; the employer may not require or direct the claimant to any specific provider on the list.

•If a listed provider prescribes invasive surgery, the claimant is entitled to a second opinion that will be paid for by the employer/insurer. Treatment recommended as a result of the second opinion must be provided by a listed provider for 90 days.

•If during the 90-day period the claimant visits a provider(s) not on the list, the employer or employer's insurance carrier may refuse to pay for such treatment.


Choice of Health Care Provider

•After the 90 days, and in situations where the employer has no posted list or an improper list, the claimant may seek treatment with any physician or other health care provider claimant selects.

•Claimant must notify the employer of the provider they have selected. During treatment, the employer or the employer's insurance carrier is entitled to receive monthly reports from your physician or provider.

•Once the claimant begins receiving WC benefits, the employer/insurer has the right to ask the claimant to see a doctor of their choice for examination. If you refuse, the employer is entitled to request an order from the WC judge requiring the claimant to attend an examination. Failure to then attend may result in a suspension of benefits.


Workers’ Compensation Office of Adjudication


How Will I Know When A Petition Is Filed By The Other Party?

•A party may file a petition electronically, by uploading a petition form, or by mailing a paper form to the Petitions Unit.

•The party filing the petition must send a copy to all other parties. The Workers' Compensation Office of Adjudication will then send you a "Notice of Assignment" telling you that a petition has been assigned and identifying the WCJ who will hear the case.


What Types of Petitions Go Before WCJs?

•Claim: Used to establish that an employee is entitled to benefits for a disputed work injury.

•Termination: Injured worker is fully recovered from a work injury, and is no longer entitled to any workers' compensation benefits from that injury.

•Suspension: Injured worker is not fully recovered, but has either returned to work or is capable of returning to available work without a loss of earnings.

•Modification: Injured worker is not fully recovered, but has either returned to work or is capable of returning to available work with some loss of earnings.

•Review: Correct errors in compensation documents (such as description of injury or average weekly wage).


What Types of Issues Go Before WCJs? (Continued)

•Review Medical: Establish whether specific health care is related to a work injury.

•Utilization Review: Address whether specific health care is reasonable and necessary.

•Seek Approval of A Compromise and Release: Ask a WCJ to approve a proposed settlement.

•Employee Challenge: Determine whether a Notification of Suspension or Modification (filed by the employer when the injured worker returns to work) is correct.


What Will Happen At The Hearing?

•The WCJ will ask both parties what evidence they intend to present. One or both parties may present testimony, submit documents, or both. The WCJ will set a schedule for the submission of all other evidence.

•The WCJ will set a schedule for presentation of evidence and submission of briefs. The Act provides that the WCJ may amend this schedule for good cause.

•The WCJ will schedule mandatory mediation (i.e., mediation required by the Act), unless he/she finds that it would be futile.

•More information concerning the WCJ's first hearing procedures may also be obtained at the Office of Adjudication Judgebook.


What is a Utilization Review ? Is this helpful for an employer?

•Employers can file utilization reviews (UR) in order to challenge the reasonableness or necessity of medical treatment a worker receives. The employer files a request with BWC, which assigns the request to a Utilization Review Organization (URO).

•Injured workers have the right to supply a personal statement to the reviewer explaining why the challenged treatment is necessary or helpful. The provider under review also has the opportunity to speak with the reviewer.

•Any party dissatisfied with the URO’s determination may file a petition with the Office of Adjudication. A WCJ will take evidence and render a decision.


What Is an IME? Does the claimant have to attend the IME?

•Section 314 of the Pennsylvania Workers' Compensation Act provides that the employer/insurance company is entitled to have the claimant examined by a doctor whom it chooses at a reasonable time and place.

•These doctors are not the treating doctors and are being paid by the employer/insurer to perform this evaluation.

•Some judges have interpreted this provision to allow for such an examination twice a year. Although the claimant is generally required to attend these exams (which are sometimes called IMEs), there are certainly exceptions. Therefore, you should speak with your attorney concerning questions related to IMEs.


Will I Get A Decision At The Hearing?

•In disputed cases, no. The law requires the WCJ's final decision to be in writing. Also, there is almost always more evidence to be given to the WCJ before the case can be decided. It often takes time to gather this evidence, especially medical records and testimony. Even if no additional evidence is needed, both parties usually want to file briefs.

How Will I Know What The WCJ Decides?

•The WCJ must send a written decision to all parties. The decision is sent after all of the evidence and briefs have been given to the WCJ. You and your attorney will receive the decision in the mail. If you have registered in WCAIS as an electronic recipient, you will receive electronic notification of the decision instead of a paper copy.


Questions

2014 governor’s occupational safety & health conference workers compensation 101 for safety...

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