Chapter 4: Participants in the System

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Questions and Answers

What is the role of the applicant's attorney in workers' compensation cases?

To represent the insurance company in court

To advocate for the injured worker’s compensation claim (correct)

To defend claims made against the insurer

To negotiate settlements with physicians

How are attorney fees for injured workers typically determined?

According to standard industry rates set annually

By negotiation between the attorney and the worker

By the workers' compensation judge or WCAB at claim resolution (correct)

By the employer based on their discretion

Under what circumstances can attorney fees be awarded from the worker’s retroactive temporary disability award?

Only when the employer is found at fault

If the WCAB mandates it after a penalty is awarded (correct)

If the employee’s claim is accepted and awarded

If the worker requests it at any time

What restrictions exist regarding attorneys and physicians taking fees from injured workers?

They are prohibited from taking fees without Appeals Board approval Signup and view all the answers

What requirement must hearing representatives meet when representing a party before the Appeals Board?

They must notify WCAB in writing of their non-licensed status Signup and view all the answers

What is a crucial reason for physicians to communicate frequently with claims administrators?

To ensure the reimbursement for treatments is authorized. Signup and view all the answers

How do claims administrators incentivize effective medical treatment?

By managing claims to ensure timely and appropriate care. Signup and view all the answers

What type of documentation is essential from physicians for a successful claims process?

Clear documentation of treatment goals and progress. Signup and view all the answers

What is the role of physicians in the workers’ compensation system?

To provide evaluations and care for injured workers. Signup and view all the answers

Which of the following describes a provider of medical goods and services under workers' compensation?

Providers that offer services necessary to treat the effects of an injury. Signup and view all the answers

Why is clear and timely communication with claims administrators critical?

It ensures prompt access to care and benefits for injured employees. Signup and view all the answers

What is one function of claims administrators during the workers’ compensation claims process?

To facilitate communication between physicians and injured workers. Signup and view all the answers

Who may represent any party involved in a workers’ compensation claim?

Attorneys, including lien claimants. Signup and view all the answers

What is the primary role of insurers in the workers' compensation system?

Assuming most of the liability for the insured employer Signup and view all the answers

Which of the following is NOT a responsibility of insurance carriers in the workers' compensation system?

Paying penalties for employer misconduct Signup and view all the answers

What must insurers provide before canceling policies for employers?

Written notice and an opportunity for the employer to contest Signup and view all the answers

What is the role of claims administrators in the workers' compensation system?

To make key decisions about the payment of benefits Signup and view all the answers

Which of the following statements about self-insured employers is correct?

They may choose to manage their own claims. Signup and view all the answers

Which of the following best describes medical case managers in the workers' compensation process?

They assist in managing medical aspects and attend physician's appointments. Signup and view all the answers

Under what circumstance can an employer terminate an injured worker during the period of temporary disability?

If the termination is due to a 'business necessity' Signup and view all the answers

What must employers do when they wish to contest a claim made by an injured worker?

Present evidence related to the claim Signup and view all the answers

What additional responsibilities do employers have under the Americans with Disabilities Act regarding injured workers?

To provide reasonable accommodations for individuals with disabilities Signup and view all the answers

What is the major role of claims administrators in workers’ compensation?

To provide a communication conduit between the employer, insurance carrier, physician, and injured worker Signup and view all the answers

Which task is NOT typically performed by a workers’ compensation claims administrator?

Training medical staff on treatment protocols Signup and view all the answers

What must a claims administrator determine regarding medical services in workers’ compensation claims?

If the services are reasonable and necessary for recovery Signup and view all the answers

What alternative terms can refer to individual claims administrators?

Claims examiners and claims adjusters Signup and view all the answers

Which statement about the frequency of services in workers' compensation is accurate?

Workers' compensation services have no arbitrary limits on frequency or duration Signup and view all the answers

What should a claims administrator do when determining liability?

Consider the physician’s report and other relevant factors Signup and view all the answers

When might a claims administrator send a request for medical treatment to utilization review?

When a request for treatment lacks adequate information Signup and view all the answers

What is a key responsibility of a claims administrator regarding case resumes?

To prepare case resumes for policyholders Signup and view all the answers

What type of organizations typically employ claims administrators?

Insurance companies and third-party administrators (TPAs) Signup and view all the answers

What is a claims administrator required to evaluate concerning assigned claims?

Accurate and adequate estimates on claims Signup and view all the answers

What is the primary role of a claims administrator in the workers' compensation system?

To select the treating physician for work-related injuries within the initial period. Signup and view all the answers

What must an employee do to initiate a claim after a work-related injury?

Complete and return the Employee’s Claim for Workers’ Compensation Benefits form to the employer. Signup and view all the answers

Who has the right to predesignate a personal physician for treatment of work-related injuries?

All employees under the California workers' compensation system. Signup and view all the answers

What happens if an employer or their insurer does not have a Medical Provider Network (MPN)?

The employee can change their treating physician to their personal chiropractor or acupuncturist. Signup and view all the answers

What is the time frame within which an employee must inform their employer about a work-related injury to qualify for compensation?

30 days Signup and view all the answers

In which situation can employees change their treating physician after the claims administrator has selected one?

Following a written request by the employee. Signup and view all the answers

What additional right does an employee have regarding treatment if no personal physician is predesignated?

They can request treatment transfer after the initial doctor visit. Signup and view all the answers

Which of the following statements is true regarding the Employee’s Claim for Workers’ Compensation Benefits form?

The employer must furnish the form within one working day of learning about the injury. Signup and view all the answers

What limitation exists for chiropractors as treating physicians after a specified number of visits?

A chiropractor cannot be the treating physician after the first 24 visits unless additional visits are authorized. Signup and view all the answers

Study Notes

Employees

California workers' compensation covers all employees, including farmworkers, domestic employees, and inmates
Federal, maritime, longshore, and railroad employees have separate systems
To receive compensation, employees must report work-related injuries/illnesses within 30 days
Employers must provide an Employee's Claim form (DWC 1) within one business day of learning of the injury
Employees have the right to choose their personal physician (predesignation)
If no personal physician is predesignated, the claims administrator usually selects the treating physician within 30 days of the company becoming aware of the injury
Employees can change to a chiropractor or acupuncturist, provided they notify their employer in writing before the injury

Employers

Employers must provide safe workplaces
They must carry workers' compensation insurance or prove self-insurance
Employers must provide workers' compensation information to employees, including claiming procedures and predesignation options
Employers must maintain records of work-related injuries and illnesses
Employers must immediately report any worker's death or serious injury (over 24 hours hospitalization, body part loss, or serious disfigurement) to the Division of Occupational Safety and Health (Cal/OSHA)
Employers must complete the Employer's Report of Occupational Injury or Illness (Form 5020) within 5 days of notification
Employers must send Form 5020 to insurer or the Division of Labor Statistics and Research (if self-insured)

Insurance Carriers and Claims Administrators

Insurance carriers are responsible for many aspects of workers' compensation claims for employees
They are responsible for processing, benefit checks, and medical cost reimbursement
Medical records are collected by insurers
Insurers must provide employers with written notices before cancellation
Insurers must allow employers to present evidence to contest a claim
Insurers employ claims administrators to manage claims
Self-insured employers can manage their own claims or hire a third party
Claims administrators receive physician reports and make benefit decisions
Administrators typically involve physician contact in claims

Claims Administrators

Claims administrators manage workers' compensation claims and are employed by insurance companies or TPAs
Tasks include determining liability, managing compensation, medical expenses, and job displacement benefits
They must determine whether medical services are reasonable and necessary to cure or relieve the affected employee
Determining if medical services are needed in a reasonable amount to produce recovery and return to function is also important
There is contact between claims administrators and their physicians for the claims process
Claims administrators are critical to resolving compensation claims efficiently and fairly to provide the best outcome for injured workers

Other Medical Providers

Other providers (e.g., doctors, labs, physical therapists) can play a crucial role in workers' compensation claims
These providers' services must be reasonably required for injury treatment

Physicians

Physicians play crucial roles in workers' compensation claims by evaluating injuries, forming treatment plans, and communicating with claims administrators
They are responsible for providing accurate evaluations for workers' compensation claims

Attorneys

Attorneys can represent parties in workers' compensation claims, including injured workers, insurers, and employers
Attorney fees are frequently a percentage of the worker's compensation award, but the percentage is determined by the judge

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Description

This quiz covers essential aspects of California's workers' compensation system for employees and employers. It includes details on employee rights, injury reporting, and employer responsibilities. Test your knowledge on the key regulations that protect workers in California.