After you finish this lesson, you will be able to:

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• Define Workers' Compensation
• Identify the steps to managing a Workers' Compensation case

Workers' Compensation is a benefits program for people who suffer a work-related illness or injury. It is a state-administered program, so exact regulations will vary by state.

The cost is shared by employers and states. Employers pay premiums, and the state subsidizes, or grants financial assistance for, the rest of the cost. Employees do not have to pay premiums to be covered.

Workers' Compensation benefits include:

Employees must report all injuries or illnesses immediately. Any witness observations must also be recorded. Then, the employer must report the incident to the company's Workers' Compensation insurance agent.

After the injury or illness has been properly reported, the employee may seek treatment. This treatment must come from the provider contracted with the employer's Workers' Compensation insurance carrier.

When handling Workers' Compensation cases, the health care provider's role will be twofold:

• Diagnose and treat the illness or injury
• Provide claims administrators with information on the case

First, the provider will obtain a complete history of the patient's present condition and a complete work history. The work history must detail any chemical or other hazardous material exposures, when relevant.

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Next, the provider must complete a physical exam and diagnose the patient. According to the diagnosis, the patient's level of disability must be assessed. The three levels of disability are:

• Medical treatment only
• Temporary disability
• Permanent disability

Within either disability category, the disability must be distinguished as either total or partial.

The medical treatment only level means that the patient may work while treatment is ongoing.

The temporary disability level means that the patient is temporarily unable to perform regular job functions.

Temporary, partial disability means that while the patient is temporarily unable to perform regular job functions, the employee could help with another job function. If they receive a lower wage, they will receive some wage benefits from Workers’ Compensation.

Temporary, total disability means that the patient will not be able to work at all while recovering, but after receiving a physician’s clearance, will be able to return to work.

Permanent disability level means that the patient is permanently unable to perform regular job functions.

Permanent, partial disability means the patient will to work again, but will never be able to return to the same line of employment.

Permanent, total disability means the patient will never work again, in any line of employment.

Finally, the provider must complete all required paperwork as promptly as possible. If unable to work, the patient will have no source of income while awaiting benefits.

Upon a Workers' Compensation patient's first visit, the assistant must work with the physician to complete the First Report of Occupational Injury or Illness. This form must be complete and correct. If more information is needed, the assistant should call the employer's personnel department.

Like with any other patient, an insurance claim form will have to be filled out for a Workers' Compensation patient. Many Workers' Compensation carriers do accept the standard insurance claim form, the CMS-1500 (02-12). However, some carriers have their own special forms.

In many Workers' Compensation cases, benefits are ongoing throughout the patient's recovery. All significant changes in the patient's condition or level of disability must be documented and reported in progress reports. Progress reports detail the patient's progress in recovery and current state of health.

Upon discharge of the patient, the physician must also issue a Final Report. A final report is like a progress report, but it states that the patient has recovered from the illness or injury.

In this lesson, you learned that:

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• Workers' Compensation provides benefits for people injured in the workplace. �It pays for medical expenses and reimburses for lost wages.
• There are specific guidelines that must be adhered to when handling a Workers' Compensation case and completing the related claim forms.
• When treating a Workers' Compensation patient, the health care provider has some responsibilities outside of just treating the patient and submitting the claim form. Other forms to be completed include the First Report of Injury or Illness, progress reports, and a final report upon discharge.