Workers Compensation For State Agencies Office of Risk

Workers’ Compensation For State Agencies Office of Risk Management Karen C. Jackson, Facilitator

Expected Workshop Goals Develop a better understanding of the workers’ comp process

Expected Workshop Goals SAVE TIME MONEY

Expected Workshop Goals Reduce some of the stress associated with workers’ compensation

ORM Workers’ Comp Statistics 6100 active workers’ compensation claims Approximately 1000 of these paid compensation benefits on regular basis

ORM Workers’ Comp Statistics $48 million spent on workers’ compensation Money comes directly from agency budgets

WORKERS’ COMPENSATION IS THE LAW! • Title 23 Louisiana Revised Statutes • Employers MUST provide workers’ compensation coverage for all employees • IW’s have the RIGHT to file a claim

Workers’ Compensation is a penalty-driven statute Anything required by the statute is subject to a penalty if • It is not done correctly • It is not done timely

Office of Workers’ Compensation Administration (OWCA) • Governing body that ensures the workers’ compensation statute is properly administered. • State agency housed under the Department of Labor • Judicial Authority – Issue Mediation Notices and Citations

Who should respond to OWCA Mediations and Citations? IW’s can file a disputed claim with Office of Workers’ Compensation ORM will respond to these on agency behalf Notify ORM adjuster when receive mediation notices and citations

Who Can Receive Workers’ Compensation? Anyone employed in the State of Louisiana who is injured on the job Coverage begins the moment employment begins Covered accidents must – arise out of employment – occur during course and scope of employment

What benefits are provided under Workers’ Compensation? IW may be entitled to medical benefits at the expense of his employer

What benefits are provided under Workers’ Compensation?

What doctor can an IW seek treatment from? • Choice of physician in each field of specialty • Approval needed to exceed $750. 00 of non -emergency medical treatment • Failure to obtain approval may result in non-payment of bills in excess of $750. 00

Can an employer have an IW examined by doctor of its choosing? • Employer or insurer has right to have IW examined from time to time during the course claim • Failure to comply with exam may result in suspension of benefits until exam takes place • Suspended period not recoverable

Who’s going to pay for this? • Employer can give verification of initial medical treatment up to $750. 00 of nonemergency treatment • Notify the adjuster of what’s been approved

Who’s going to pay for this? • IW should NEVER pay out-of-pocket for medical services or use personal insurance to pay for medical expenses that result from a work related accident.

How long does IW have to file a claim for medical benefits? Claims for medical benefits must be filed within 1 year from date of accident Period for medical benefits is 3 years from date of last payment

What benefits are provided under Workers’ Compensation? IW may be entitled to income benefits at the expense of employer

What benefits are provided under Workers’ Compensation? Provisions for – Surviving spouse – Dependent children or – Surviving parents in the event of work related death.

What benefits are provided under Workers’ Compensation? Surviving spouse and dependant children – Entitled to weekly benefits Surviving parents – Lump sum • $75, 000 each if – No surviving spouse – No dependent children $7500 burial expense

How long does IW have to file a claim for indemnity benefits? • Claims for weekly benefits must be filed within 1 year from date of accident • Weekly benefits open 1 year from date of last payment • 3 years from date of last payment for SEB

CIVIL SERVICE RULE 11. 21 Workers’ Compensation Payments When an employee is absent from work due to disabilities for which he is entitled to workers’ compensation he (a) shall, to the extent of the amount accrued to his credit, be granted sick leave not to exceed the amount necessary to receive total payments for leave and workers’ compensation equal to his regular salary. (b) may, to the extent of the amount accrued to his credit, be granted annual leave or a combination of annual and sick leave not to exceed the amount necessary to receive total payments for leave and workers’ compensation equal to his regular salary. (c) may be granted leave without pay.

CIVIL SERVICE RULE 11. 21 Questions about leave with respect to workers’ compensation should be directed to Civil Service

Exclusive Remedy • An IW cannot sue his employer in tort or for negligence, unless • Employer intentionally tried to harm the IW

When should IW report an accident? Injured workers must notify immediate supervisor – as soon as an accident occurs

What should the supervisor do when an accident is reported? Supervisor immediately initiates paperwork for E-1 to be sent to ORM – Paper – Electronically

When should ORM be notified of an accident? Please notify ORM immediately of all accidents – Even if IW has enough sick leave to cover accident – Do not require IW to exhaust all of sick leave before ORM is notified Benefits due 14 days from date employer notified of accident

DON’T DROP THE BALL! DO NOT deny employees the right to file a claim – Increased litigation exposure – A filed claim does not mean a paid claim

Incidents Not Covered

Incidents Not Covered IW intentionally injures himself or another employee

Incidents Not Covered IW deliberately failed to use adequate protection provided

Incidents Not Covered IW intoxicated at the time of the accident -alcoholic beverages -Rx -OTC -illegal narcotics Burden of proof on employer

Incidents Not Covered IW who is proven to be the aggressor unprovoked altercation

Incidents Not Covered Injuries resulting from Horseplay

Incidents Not Covered Incidents which arise out of purely personal matters

Items Not Covered Personal items damaged in work-related accidents

“Gray” Coverage Areas

“Gray” Coverage Areas Mental stress

“Gray” Coverage Areas Heart attacks Strokes

Gray” Coverage Areas Clear and convincing evidence that these are – – Sudden Unexpected Extraordinary Related to the employment Cannot be related to – Any other health condition – Personal situation

Are volunteers and community service workers covered for Workers’ Compensation? • Covered for medical payments only • Community service must be ordered by State court

When is IW entitled to receive WC Benefits? Eligibility to receive WC lost time benefits begins when injury prevents IW from RTW for more than 7 calendar days 7 day waiting period Benefits payable on 8 th day 1 st 7 days not recoverable • unless IW loses more than 42 calendar days

When is the first indemnity check due? Comp checks are due 14 days after employer notified of accident

How are weekly benefits calculated? Based on 66 2/3 % – average weekly wage (AWW) – up to maximum (Maximum is $454. 00)

How are weekly benefits calculated? If a worker earns less than the minimum – actual wage is comp rate Maximum and minimum – change every September 1 st Wages locked according to date of accident – in most cases

How are indemnity benefits initiated? To initiate benefits – Adjuster enters benefit record when claim setup OR – When lost time begins

WHEN ARE CHECKS PRINTED? INDEMNITY BENEFIT RECORD – Updated every other Monday – Checks generated every other Monday night or – Nearest date to regular pay day if holiday

WHEN ARE CHECKS MAILED? EVERY OTHER TUESDAY

Where is the indemnity benefits check mailed? Usually mailed to agency or region of employment Must be mailed directly to injured worker if requested

RS 23: 1201. 1 WORKERS’ COMPENSATION PAYMENTS, AT THE OPTION OF THE EMPLOYEE, SHALL BE MAILED TO THE EMPLOYEE AT THE ADDRESS DESIGNATED BY HIM.

HOW LONG IS THE CHECK GOOD? CHECKS EXPIRE 180 DAYS FROM ISSUE DATE

TELL US! COMP CHECK INCORRECT – TOO MUCH – TOO LITTLE – WRONG DATES

TELL US! EMPLOYEE OUT OF LEAVE – We don’t know until you tell us

TELL US! RETIRE QUIT BACK AT WORK

TELL US! WHEN AGENCY PERSONNEL CHANGES

How to get a check voided, reissued or payment stopped Notify the adjuster of record – Supplemental – Phone – Email Name and phone number on check stub.

Can IW be on WC and FMLA? Employee can be on workers’ compensation and Family Medical Leave at the same time. • Run concurrently

Can Workers’ Compensation injuries qualify for ADA protection? Some workers’ compensation injuries may qualify for accommodations under the Americans with Disabilities Act.

What if IW can RTW in a lesser capacity? If IW worker can earn wages but – Unable to earn wages equal to 90% or greater of preinjury wage ENTITLED TO SEB – SEB based on 66 2/3 of difference between • pre-injury wage and • what employee is now capable of earning

When do workers’ compensation benefits stop? Once WC benefits are started – They continue until IW returns to work OR Is released to RTW, regular duties by treating physician

What can be done to stop WC benefits? Only way to stop payments altogether

Transitional Duty Employment

What is Transitional Duty Employment? TDE is that employment which enables an IW to go from here

Transitional Duty Employment To here

Stop and think about it! Would you like for your employee to sit here?

Stop and think about it! Or here?

When is Transitional Duty Employment done? Transitional Duty Employment is feasible – IW released to some form of employment TP decides RTW – Can’t RTW before doctor says so

When is Transitional Duty Employment done? When IW unable to return to his previous work OR Unable to earn wages equal to his pre-injury wage

What should an employer do when IW is released to restricted duties? Make every effort to –return IW back to work • same employer –even if IW cannot return to work full duties

What if there is no Transitional Duty Employment? R. S. 23: 1226 – Rehabilitative services • Job placement • Retraining

Transitional Duty Employment When an employee is sitting home collecting a comp check -

Who’s going to do that work? The work piles up!!!

It doesn’t matter what you call it! • • Job modification Light duty Restricted duty Transitional Duty Employment – Cuts cost of workers’ compensation claims

Successful Transitional Duty • Open mind of employer required • Employer must make accommodations when IW has been released to some form of restricted duty

Successful Transitional Duty Agency involvement is required – Committed to TDE – Communicate with the injured worker

Successful Transitional Duty Employers should exercise discretion and caution in determining the transitional duties to be assigned.

Successful Transitional Duty Transitional duty employment must not lower the performance standards and expectations of the job as a whole

Successful Transitional Duty Transitional duty employment should not establish a precedent for a lower level of duties and performance that other employees might then expect to be applied to them

Successful Transitional Duty Transitional duty employment should not have the effect of permanently lowering the employee’s Civil Service job title.

Transitional Duty Works • Effective in both public and private sector • 20% decrease in disability costs • Keep productivity and employee moral up • Get employee back into work environment as soon as medically possible

Transitional Duty Works • • Economical IW benefits Employer benefits RTW makes good business sense • IT’S A WIN – WIN SITUATION

Successful Transitional Duty Department of Civil Service, Program Assistance Division can give guidance in evaluating transitional duty employment.

Can IW receive both retirement and Workers’ Compensation? Disability Retirement – benefits may be reduced Regular Retirement – benefits payable for 2 years • gainfully employable ORM must be notified immediately

Can IW receive unemployment and Workers’ Compensation? CAN’T GET BOTH – Workers’ Compensation – Unemployment Benefits Notify the handling adjuster immediately

Attorneys • IW not required to have an attorney • Cannot discourage anyone from retaining an attorney • Drive up the cost and settlement value of claims

Are Independent Contractors covered under State workers’ compensation? • Ensure contractor has WC coverage for its employees • If coverage lapses – State can be deemed the statutory employer of their employee - Must provide WC to their employees • Check solvency of contractor periodically

What form is used to file a WC claim? • Employers’ First Report (E-1) • Five page form – Original ORM – OWCA • > 7 days disability • Death • Amputation / Disfigurement – Employer – Injured Worker – Treating Physician

Completing the E-1 • Social Security Number • Location Code • Purpose of the report is important – More than seven (7) days lost time – Death / amputation / disfigurement – Medical only – Possible dispute

Completing the E-1 • • Complete MM/DD/YY Time of day Date IW RTW Date disability began – if not back at work • Complete – Name – Current residential address including city, state, zip – Current phone number • Occupation

Completing the E-1 Place of accident is important – On the premises – On someone else’s premises These effect coverage

Completing the E-1 What was IW doing when accident occurred – Defenses • Horseplay • Intoxication • Personal conflicts – Course and scope of employment – Arising out of the employment

Completing the E-1 Complete details on how injury occurred Is the accident due to mechanical defect – or An unsafe act?

Completing the E-1 If incident is result of MVA: – who’s at fault • (who hit whom)? Subrogation rights

Completing the E-1 Retain damaged property – Product Liability

Completing the E-1 • Part of body / nature of injury important What’s wrong with IW? • If leg, arm, eye, ear, fingers or toes are hurt: – which one? • Treating physician / hospital – – address and phone number

Completing the E-1 Name of Employer – Identify • region • district

Completing the E-1 Always give wage even if IW does not lose time Report wage on WEEKLY basis – overtime earned in the four (4) weeks prior to date of accident – Report any premium or differential pay – Report income that is taxable to employee – Report any part-time employment or second jobs

Communication Share information with adjuster that will be helpful in making a determination on the claim. – This can be done at any time during the claims process.

DID YOU KNOW? Report workers’ compensation claims on-line using a web-based application

Claims Reporting: the “OLD” Way Type claim form Write out E-1

Claims Reporting: the “OLD” Way Send claims through the mail or by fax

Claims Reporting: the “OLD” Way Wait for mail to be delivered to ORM

Claims Reporting: the “OLD” Way Your Claim At ORM!!!

ONLINE CLAIMS REPORTING ELIMATES: – Typewritten claims – Handwritten forms – Faxing Reduces time to receive claim Instant claim set-up Easier to authorize medical treatment

ONLINE CLAIMS REPORTING Once trained, no paper claims will be accepted

Supplemental Report Of Injury Notify ORM of changes in claim status – Beginning disability – Return to work – Corrected wage reporting – Corrected dates of loss – Retirement status

Drug Screening • Post-accident drug screen WC accidents • WC Statute: deny if IW is intoxicated at the time of the accident • Intoxication can be due to alcohol, Rx, OTC medication or illegal narcotics • Employer MUST have a written policy

Drug Screening • RS 23: 1081(1)(b) has guidelines on what constitutes policy • ALL employees must be made aware of the policy • Post-accident screening paid in conjunction with the WC claim • 0. 08 % or greater of alcohol = intoxication • Screen pre-RTW (R. S. 23: 1221. 3. g)

Records Retention • ORM maintains all closed files for two (2) years on-site • Files are archived for three (3) years then destroyed

What forms should be sent to ORM? • E-1 • Supplemental Report of Injury • Employer’s Certificate of Compliance

POST-OFFER OF EMPLOYMENT MEDICAL INQUIRY (E-2) • Used to secure second injury fund approval only • Must be kept confidential • Will be housed at agency of employment • Must be updated every 2 years

POST-OFFER OF EMPLOYMENT MEDICAL INQUIRY (E-2) • Compliant with HIPPA ADA FMLA

What is the Second Injury Fund? • SIF established by the legislature to encourage employers to hire / retain persons with pre-existing disabilities • Insurance companies pay a percentage of their workers’ compensation premiums into the fund • Claims are filed with SIF on all qualified claims

Second Injury Fund • Employer knowledge of pre-existing disability key to SIF approval • Written statement needed from the employer about knowledge of pre-existing condition before the accident occurred • Knowledge can be: disclosures on insurance and/or retirement forms / prior workers comp claims / E-2

Second Injury Fund • Over $2. 0 million received in recoveries last year • Reimbursements credited against the qualifying claim • Reduce the cost of the claims and premiums

Second Injury Fund - Vendor • ORM utilizes a contract vendor to help identify and secure SIF approval • Please work with vendor to provide needed information to get approvals

HANDOUT

Workers’ Compensation For State Agencies

? ? ? Questions ? ? ? • Are there any questions?