Chapter 14 Workers' Compensation

Question 1

Workers’ Compensation

Answer 1

Workers’ Compensation is a benefit program that requires an employer to pay, or provide insurance to pay, for the lost wages and medical expenses of an employee who is injured on the job.

Question 2

Workers’ Compensation

Answer 2

Independent contractors are not entitled to workers’ compensation benefits, and in some states domestic workers and agricultural workers are excluded or only partially covered.

Question 3

Purpose and Scope

Answer 3

*Workers’ compensation is considered a no-fault insurance program, meaning an injured

*Employee will receive benefits regardless of who was at fault (the employer, the employee, a patient, etc.

Question 4

Segregation of Documentation

Answer 4

Workers’ compensation insurance payers and the state compensation boards/commissions are allowed by law to review only treatment data and history pertaining to the patient’s on-the-job injury.

Question 5

Segregation of Documentation

Answer 5

Maintaining separate charts for workers’ compensation injuries is essential to ensure the correct information is being submitted.

Question 6

HIPAA Privacy Rule does

Answer 6

not apply to entities that are either workers’ compensation insurers, workers’ compensation administrative agencies, or employers, except to the extent they may otherwise be covered entities.

Question 7

HIPAA Privacy Rule does

Answer 7

Providers who treat patients for workers’ compensation injuries or illness must create a separate chart for documentation of the work-related injury and treatment.

Question 8

BILLING TIP

Answer 8

It is important to keep the work related and non-work-related documentation separate. If paper charts are utilized, having a separate chart for the work-related injury is required. Make the chart a different color to make it easy to identify. If EHR/EMR is used, open a separate progress note and identify it in a way that will make it easy to recognize the work-related injury.

Question 9

Occupational Safety & Health Administration (OSHA)

Answer 9

This department was created to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance.

Question 10

Those not covered by OSHA include

Answer 10

*self-employed,

*Immediate family members of farm employers that do not employ outside workers,

*and injuries covered by another federal agency (for example, the Coast Guard).

Question 11

According to OSHA,

Answer 11

the healthcare and social assistance industry have more work-related injuries and illness than any other sector.

Question 12

Orderlies …

are now called

Answer 12

Patient Care Assistant and CNA

Question 13

Healthcare workers include medical staff, maintenance, housekeeping, food service, laundry, and administrative staff. Healthcare workers face many serious safety and health hazards.

Answer 13

*These hazards include bloodborne pathogens and biological hazards,

*potential chemical and drug exposures, waste anesthetic gas exposures, respiratory hazards,

*ergonomic hazards from lifting and repetitive tasks, laser hazards, workplace violence,

*hazards associated with laboratories, and radioactive material and X-ray hazards.

Question 14

Coverage and Provider Reimbursement

Answer 14

To qualify for workers’ compensation, an employee must be injured while working within the scope of their job description, injured while performing services required by the employer, or contract an illness that can be directly connected to employment.

Question 15

Payment of Premiums
Federal and state laws require employers to maintain workers’ compensation coverage.

Answer 15

Federal employees are covered under one of the federal workers’ compensation programs.

Question 16

Energy Employees Occupational Illness Compensation Program (EEOICP)

Answer 16

Provides lump-sum compensation and health benefits for eligible Department of Energy nuclear weapons workers (including employees, former employees, contractors, and subcontractors) injured on the job.

Question 17

Federal Employees’ Compensation Program—The Federal Employees’ Compensation Act (FECA) provides workers’ compensation coverage to three million federal and postal workers around the world for employment-related injuries and occupational diseases.

Answer 17

The Division of Federal Employees’ Compensation (DFEC) adjudicates new claims for benefits and manages ongoing cases.

Question 18

All medical authorizations and claims processing are handled by a contractor, which at this writing is ACS.

Answer 18

ACS provides an online tool at https://www.dol.gov/owcp/dfec/regs/compliance/WebPortal.htm where injured workers, medical providers, or employing agencies can:

*check eligibility
*check authorization
*check bill payment

Question 19

Section Review 14.1

Under Workers’ Compensation, when is a worker covered for an injury that occurred on-the-job?

Answer 19

Answer: C. They are covered regardless of who is at fault.

Question 20

Which program covers postal workers for employment related injuries?

Answer 20

Answer: B. Federal Employees’ Compensation Program

Question 21

Can an employer require an employee to pay a portion of the insurance premiums for the workers’ compensation coverage? Why or why not?

Answer 21

Answer: D. No, the employer is required by law to pay the premiums for coverage.

Question 22

A patient presents to be seen with chronic beryllium disease that he incurred while under government employment. What coverage would apply to him?

Answer 22

Answer: A. Part B Energy Employees Occupational Illness Compensation Program

Question 23

According to OSHA, who has the highest rate of work-related musculoskeletal disorders?

Answer 23

Answer: C. Nurses’ aides

Question 24

Longshore and Harbor Workers’ Compensation Program (LHWCP)—

Answer 24

The Longshore and Harbor Workers’ Compensation Program provides workers’ compensation benefits to most waterfront workers and contractors working overseas for the U.S. government.

Question 25

The Federal Black Lung Program

Answer 25

*is an act providing compensation and medical coverage for treatment to coal miners who are totally disabled by pneumoconiosis arising out of coal mine employment,

*and to survivors of coal miners whose deaths are attributable to the disease

Question 26

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Individuals injured on the job while employed by private companies or state and local government agencies would be covered by insurance payers through their state workers’ compensation board.

Answer 26

The workers’ compensation law is governed by each state.

Question 27

State Insurance Fund—

Answer 27

An agency that provides workers’ compensation insurance coverage to private and public employers and acts as an agent in state workers’ compensation cases involving state employees.

Question 28

Self-Insurance Plans—

Answer 28

Employers with adequate capital to qualify can self-insure.

Question 29

Commercial Workers’ Compensation Insurance—

Answer 29

Commercial insurance companies that meet state mandates for workers’ compensation coverage can offer policies for employers to purchase.

Question 30

Combination Programs—

Answer 30

In some states, employers can choose a combination of any of the above to comply with workers’ compensation coverage requirements.

Question 31

Reimbursement Requirements for Providers

Answer 31

Providers are required to accept reimbursement from workers’ compensation payers as payment in full.

Question 32

Claims Completion

Answer 32

*When an employee is injured on the job, a claim is filed with the employer’s workers’ compensation carrier.

*Once a claim is filed, the date of injury/illness is established, and the employee is assigned a claim number.

*This claim number acts as the equivalent of an insurance ID number when filing medical claims for reimbursement

Question 33

The claim will be submitted to the workers’ compensation payer in paper format using a CMS 1500 claim form.

Answer 33

A First Report of Injury form and the progress note for the encounter must also be submitted with the paper claim.

Question 34

The filing deadline for the first report of injury is determined by state law.

Answer 34

The deadline for filing of the claim for services will vary by payer.

Question 35

What must be submitted to the workers’ compensation payer after an initial employee injury visit?

Answer 35

Answer: D. First Report of Injury form, CMS-1500 claim form, and office encounter note

Question 36

A 70-year-old patient with complex pneumoconiosis presents after a fall. X-rays are taken and are negative for fracture. The patient gives both a Medicare card and a Federal Black Lung ID card. How should this claim be billed?

Answer 36

Answer: C. Medicare only

Rationale: Federal Black Lung only pays claims that relate to conditions from the pneumoconiosis. This patient fell and had X-rays that are not related to his lung condition. Therefore, Medicare would be the only payer billed for this visit.

Question 37

What type of state workers’ compensation coverage allows an employer to set aside money to cover medical expenses and other related benefits for its employees?

Answer 37

Answer: B. Self-insurance plans

Question 38

What kind of workers are covered under the Longshore and Harbor Workers’ Compensation Program?

Answer 38

Answer: C. i and iv

Rationale: The LHWCA covers workers in traditional maritime occupations, such as longshore workers, shipbuilders, ship-repairers, and harbor construction workers. The LHWCA specifically excludes seamen, employees of the U.S. government or of any state or foreign government, employees whose injuries were caused solely by their intoxication, and employees whose injuries were due to their own willful intention to harm themselves or others.

Question 39

What is the timely filing limit for claims for workers’ compensation services?

Answer 39

Answer: B. Will vary by payer

Question 40

Combination Programs

Answer 40

In some states, employers can choose a combination of coverage options (state, commercial, or self) to comply with workers’ compensation coverage requirements.

Question 41

Energy Employees Occupational Illness Compensation Program

Answer 41

Provides lump sum compensation and health benefits for eligible Department of Energy nuclear weapons workers injured on the job.

Question 42

Federal Black Lung Program

Answer 42

An act which provides compensation and medical coverage for treatment to coal miners

Question 43

Longshore and Harbor Workers’ Compensation Program—

Answer 43

waterfront workers and contractors working overseas for the U.S. government.

Question 44

OSHA

Answer 44

Occupational Safety and Health