Vanessa Garcia Post: Describe Special Handling Practices

Vanessa Garcia post describe Special Handling Practices For Workers Com

Vanessa Garcia post describe special handling practices for workers’ compensation cases. Special Handling Contacts the employer immediately when an injured worker presents for the first visit without a written or personal referral from the employer. Contact the workers’ compensation board of the state where the work-related injury occurred. No patient signature is needed on the First Report of Injury form, Progress Report, or billing forms. If an established patient seeks treatment of a work-related injury, a separate compensation chart and ledger/account must be established for the patient.

The First Report of Injury form requires a statement from the patient describing the circumstances and events surrounding the injury. Progress reports should be filed when there is any significant change in the patient’s condition and when the patient is discharged. Prior authorization may be necessary for nonemergency treatment.

Explain how managed care applies to workers’ compensation coverage. Both employees and employers have benefited from incorporating managed care into workers’ compensation programs, thereby improving the quality of medical benefits and services provided. For employers, managed care protects human resources and reduces workers’ compensation costs.

For employees, the benefits include: â— More comprehensive coverage, because states continue to eliminate exemptions under current law like small businesses and temporary workers; expanded health care coverage if the injury or illness is work-related and the treatment/service is reasonable and necessary; provision of appropriate medical treatment to facilitate healing and promote prompt return to work; internal grievance and dispute resolution procedures involving the care and treatment provided by the workers’ compensation program, along with an appeals process to the state workers’ compensation agency; coordination of medical treatment and services with other services designed to get workers back to work; no out-of-pocket costs for coverage or provision of medical services and treatment; cost/time limits do not apply when an injury or illness occurs.

Describe workers’ compensation appeals and adjudication processes. When a workers’ compensation claim is denied, the employee can appeal the denial to the state Workers’ Compensation Board and undergo adjudication, a judicial dispute resolution process in which an appeals board makes a final determination. All applications for appeal should include supporting medical documentation of the claim when there is a dispute about medical issues. If the appeal is successful, the board will notify the health care provider to submit a claim to the employer’s compensation payer and refund payments made by the patient to cover medical expenses for the on-the-job illness or injury.

Workers’ Compensation provides weekly cash payments and reimburses health care costs for covered employees who develop a work-related illness or sustain an injury on the job. It also provides payments to qualified dependents of the worker who dies from a compensable illness or injury. To qualify for WC, the employer must be injured while working within the area of the job description, injured while performing a service required by the employer, or develop a disorder directly related to employment, such as mercury poisoning. Workers' Compensation cases are handled specially because providers are required to accept the workers’ compensation-allowable fee as payment in full for covered services rendered on cases involving on-the-job illnesses and injuries. An adjustment to the patient’s account must be made if charges exceed the approved reimbursement for the treatment.

In my experience working in an Orthopaedic Office, WC cases covered office visits, therapy, and potentially surgery. Managed care applies significantly to WC coverage by improving service quality and reducing costs. Both employees and employers benefit: employees receive broader, more comprehensive coverage with coordination of care, and employers see reductions in WC expenses. When a WC claim is denied, the process involves appealing to the state Workers’ Compensation Board, which conducts a judicial adjudication. During the appeal, depositions are taken, where parties answer questions under oath. If the appeal is successful, the board instructs providers to submit claims for reimbursement and refunds payments made by the employee.

References

• Green, Michelle A. (2020). Understanding health insurance: A guide to billing and reimbursement. 13th Edition. Cengage Learning.
• Baldwin, L. M., & Taylor, K. (2017). Workers' compensation and managed care: An overview of policies and practices. Journal of Occupational and Environmental Medicine, 59(3), 233-240.
• U.S. Department of Labor. (2022). Workers’ Compensation programs. https://www.dol.gov/agencies/owcp
• National Council on Compensation Insurance (NCCI). (2019). Workers’ compensation data and analysis.
• Leigh, J. P., & Miller, T. R. (2017). Occupational injury and illness surveillance: A review of current systems and challenges. American Journal of Preventive Medicine, 52(3), 446-455.
• Hart, A. R. (2018). Managing workers’ compensation claims and legal issues. Journal of Legal Medicine, 39(2), 149-160.
• Schultz, A. M., & Waid, J. M. (2019). The role of managed care in workers’ compensation: Benefits and challenges. Healthcare Management Review, 44(1), 48-58.
• Illinois Workers' Compensation Commission. (2021). Workers’ compensation claims process and appeals procedures.
• Thirteenth Edition; Green, Michelle A. (2020). Understanding health insurance: A guide to billing and reimbursement.
• American Medical Association. (2021). Guidelines for workers’ compensation billing and documentation.