For an injured employee to receive benefits, the worker needs to follow the workers’ compensation claims process, including filing a claim before the state deadline. If a worker is injured on the job, there is a limited amount of time to submit paperwork in order to receive workers’ compensation benefits. Both the worker and the employer must act promptly when an injury occurs. Otherwise, the claim could be denied. When an injury occurs, there are a few options:
The employer must:
• Give the employee the appropriate paperwork and guidance
• File the claim with the insurer
• Comply with state law for reporting work injuries
The employee must:
• Notify the employer of the injury (date, time, type of injury, and how it occurred)
• File a formal workers’ comp claim
Problem Statement
The workers' compensation process is complicated and each of the steps outlined below can be confusing, complicated and daunting to the employee. Often employees simply do not have the knowledge to navigate this complex process on their own.
How the Workers' Comp process works:
1. The Employee Reports An Injury To The Employer
To make a workers' comp claim, the employee's injury or illness must be work-related. A variety of injuries may qualify, such as slipping on an icy patch in the business parking lot or developing cancer from exposure to toxic substances in the workplace.
In emergency situations, the employee should be rushed to a hospital emergency room. For less immediate concerns, injured workers should go to a doctor to get a diagnosis and receive a medical report to file with the workers’ comp claim.
Depending on the state and the insurer, the employee may need to visit a medical provider that’s part of the insurer’s network to receive benefits.
The employee should provide written notice of the injury as soon as possible. Reporting deadlines vary by state. For example, the employer must be notified within 30 days in New York, while other states allow employees up to a year or two to report the injury. With injuries or illnesses that surface over time, such as mesothelioma (caused by exposure to asbestos), the employee should report the illness as soon symptoms occur.
2. The Employer Provides The Necessary Paperwork To The
Employee
Once the employer has been notified about the injury, the employer should give the employee:
• The proper reporting forms for the workers’ comp insurance provider
• A form for reporting to the state workers’ comp board (depending on state law)
• Information on the employee’s rights and workers’ comp benefits
• Information about returning to work
If possible, employers should provide this information before the injured employee seeks treatment. Some businesses include workers' comp insurance information in the employment packet for new hires. Failure to provide this information to injured employees could lead to lawsuits.
3. The Employer Files The Claim
Usually, the employer is responsible for submitting the paperwork to the workers’ comp insurance carrier, but the employee’s doctor also needs to mail a medical report.
Additionally, employers may need to submit documentation to the state workers' compensation board. This may apply for all workplace injuries, even if the employee is not seeking workers’ comp benefits.
4. The Insurer Approves Or Denies The Claim
Once the claim is filed, the insurer will make a determination. If the claim is approved, the insurer will contact the employee for payment detail. If the insurer doesn’t think the claim qualifies for workers’ compensation benefits, it will be denied. A workers' compensation benefits denial could be appealed through an adjuster.
The rest of the process is between the employee and his or her legal representation (if any), doctors, and the insurance company.
If the insurer approves the claim, the employee can:
• Accept the payment offer, which may cover costs for medical bills, medicine, disability payments, and a portion of lost wages
• Negotiate for a lump-sum settlement or larger structured settlement
If the insurer denies the claim:
• The employee can ask the insurance company to review the decision
• The employee can appeal
In both instances, the insurance provider will notify the workers’ comp board of its decision.
5. The Employee Returns To Work
The employee must notify both the employer and insurance company via written notice when he or she has recovered sufficiently and wishes to return to work. Depending on the severity of the injury, the insurance company may continue paying disability benefits.
If employees continue to experience occupational injuries, a company’s workers’ comp premium may increase.
Solution
Having a 24/7 Nurse Advice/Injury Reporting Hotline and a Nurse Case Management Program will have a significant positive impact to the outcome of the claim for both the worker and employee. These two programs work in concert with each other to help direct the employee to the right level of care and to manage costs for the employer by intervening at each step of the process.
As an example, a company utilizing a dedicated Nurse Case Manager in conjunction with an Injured Workers 24/7 Reporting Hotline allows the injured worker to speak with a live nurse whenever they experience a work-related injury or incident. This number connects the injured worker with a team of Registered Triage Nurses who utilize Schmidt/Thompson medical guidelines to triage the caller’s symptoms. The triage nurse directs the caller to the employers preferred medical providers and reports the injury to the employer and to the dedicated Nurse Case Manager. The employer is already enjoying cost savings as a result, and the injured worker is feeling like they are being taken care of.
The dedicated Nurse Case Manager begins work on the case within one business day of the report of injury. The Nurse Case Manager’s routine intervention includes:
• Discussions with the employer to identify barriers and/or red flags
• Follow up with the injured worker to ensure they have sought treatment from the appropriate medical provider and answer questions regarding medical treatment
• Communication with the medical provider to discuss any barriers to return to work and to pre-injury status
• Authorize treatment as applicable, the same day treatment requests are received from the provider
• Coordinate a release to return to work from the medical provider and transitional employment accommodations with the employer, when applicable
Outcome
The Nurse Advice Line injury reporting process reduces the time between injury and reporting allowing the dedicated Nurse Case Manager the opportunity to begin facilitating treatment and return to work at the beginning stage of the claim. The Nurse Case Manager works closely with the injured worker to ensure their accountability with attending appointments, but also assists with scheduling follow-up appointments, and specialist and therapy appointments, avoiding unnecessary delays in treatment. The Nurse also authorizes appropriate treatment immediately and coordinates with the medical provider and employer to return employees back to work as soon as possible and with modified employment accommodations where applicable. The resulting cost savings were can be significant.
In a recent White Paper Professional Dynamics of California reported the outcomes of such a program from a large California Public Entity client. Outcomes of implementing this program are as follows:
• After the first year of the program, the entity saw a 56% reduction in days away from work, including a 61% reduction in days away from work for the Department of Public works.
• After 3 years, the average medical cost per claim was down 53%, from $5,526 per claim to $2,571, and the number of total disability cases was reduced by 20%.
• After five years of the program, the days away from work were reduced an average of 62% from the year prior to program implementation, 68% for the Department of Public Safety.
Additionally, the clients saw a substantial positive impact on employee morale and understanding of the workers’ compensation process. When asked employees provided feedback that detailed their trust in the dedicated Nurse Case Manager, and how the Nurse’s involvement made them feel at ease about the process.
Over 5 years, this client saw an 81% reduction in litigated claims.
Conclusion
Having a 24/7 Nurse Reporting Injury line and a dedicated Nurse Case Manager will shape the future of any worker's comp claim. Offering this service to employees both reduces medical dollars and days away from work, additionally it also provides the injured worker with an advocate for their medical concerns. This advocacy can contribute to a substantial improvement in injured workers cooperation with the medical treatment plan, resulting in faster recovery times and earlier return to work. The Nurse Case Manager also establishes solid relationships with the medical providers, gaining cooperation from the physicians in releasing employees to modified duty.
This program demonstrated the importance of early intervention of a workers’ compensation injury and how this intervention has a direct impact on medical dollars and days away from work. The program also demonstrates the substantial influence a dedicated case manager has on relationships with providers, injured workers, and the overall outcome of the claim.
Schedule a consultation with a PDI account specialist to discuss how this program can help your organization now.
I hope you enjoyed this blog post about the major steps in the worker's compensation claims process.
Interested in more articles about workers' compensation?
Read Related Resources:
• How To Cut Costs For Worker's Compensation Insurance
• An Overview On Workers' Compensation Basics
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