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?

<p>They are prohibited from taking fees without Appeals Board approval (A)</p> Signup and view all the answers

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

<p>They must notify WCAB in writing of their non-licensed status (D)</p> Signup and view all the answers

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

<p>To ensure the reimbursement for treatments is authorized. (D)</p> Signup and view all the answers

How do claims administrators incentivize effective medical treatment?

<p>By managing claims to ensure timely and appropriate care. (D)</p> Signup and view all the answers

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

<p>Clear documentation of treatment goals and progress. (C)</p> Signup and view all the answers

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

<p>To provide evaluations and care for injured workers. (B)</p> Signup and view all the answers

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

<p>Providers that offer services necessary to treat the effects of an injury. (A)</p> Signup and view all the answers

Why is clear and timely communication with claims administrators critical?

<p>It ensures prompt access to care and benefits for injured employees. (D)</p> Signup and view all the answers

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

<p>To facilitate communication between physicians and injured workers. (D)</p> Signup and view all the answers

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

<p>Attorneys, including lien claimants. (A)</p> Signup and view all the answers

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

<p>Assuming most of the liability for the insured employer (B)</p> Signup and view all the answers

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

<p>Paying penalties for employer misconduct (C)</p> Signup and view all the answers

What must insurers provide before canceling policies for employers?

<p>Written notice and an opportunity for the employer to contest (D)</p> Signup and view all the answers

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

<p>To make key decisions about the payment of benefits (D)</p> Signup and view all the answers

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

<p>They may choose to manage their own claims. (B)</p> Signup and view all the answers

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

<p>They assist in managing medical aspects and attend physician's appointments. (A)</p> Signup and view all the answers

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

<p>If the termination is due to a 'business necessity' (C)</p> Signup and view all the answers

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

<p>Present evidence related to the claim (D)</p> Signup and view all the answers

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

<p>To provide reasonable accommodations for individuals with disabilities (A)</p> Signup and view all the answers

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

<p>To provide a communication conduit between the employer, insurance carrier, physician, and injured worker (A)</p> Signup and view all the answers

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

<p>Training medical staff on treatment protocols (A)</p> Signup and view all the answers

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

<p>If the services are reasonable and necessary for recovery (C)</p> Signup and view all the answers

What alternative terms can refer to individual claims administrators?

<p>Claims examiners and claims adjusters (B)</p> Signup and view all the answers

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

<p>Workers' compensation services have no arbitrary limits on frequency or duration (D)</p> Signup and view all the answers

What should a claims administrator do when determining liability?

<p>Consider the physician’s report and other relevant factors (A)</p> Signup and view all the answers

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

<p>When a request for treatment lacks adequate information (B)</p> Signup and view all the answers

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

<p>To prepare case resumes for policyholders (A)</p> Signup and view all the answers

What type of organizations typically employ claims administrators?

<p>Insurance companies and third-party administrators (TPAs) (D)</p> Signup and view all the answers

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

<p>Accurate and adequate estimates on claims (A)</p> Signup and view all the answers

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

<p>To select the treating physician for work-related injuries within the initial period. (A)</p> Signup and view all the answers

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

<p>Complete and return the Employee’s Claim for Workers’ Compensation Benefits form to the employer. (D)</p> Signup and view all the answers

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

<p>All employees under the California workers' compensation system. (C)</p> Signup and view all the answers

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

<p>The employee can change their treating physician to their personal chiropractor or acupuncturist. (A)</p> 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?

<p>30 days (D)</p> Signup and view all the answers

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

<p>Following a written request by the employee. (A)</p> Signup and view all the answers

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

<p>They can request treatment transfer after the initial doctor visit. (C)</p> Signup and view all the answers

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

<p>The employer must furnish the form within one working day of learning about the injury. (C)</p> Signup and view all the answers

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

<p>A chiropractor cannot be the treating physician after the first 24 visits unless additional visits are authorized. (B)</p> Signup and view all the answers

Flashcards

Claims Administrator

These professionals are responsible for managing and processing workers' compensation claims. They handle benefits, authorizations, and communication.

Physician-Claims Administrator Communication

Regular communication between physicians and claims administrators is crucial in workers' compensation cases. This ensures the injured worker receives timely and appropriate care, as well as benefits and a smooth return to work.

Transitional Work

This involves creating a plan for the injured worker to gradually return to work by modifying tasks or providing alternative duties.

Prognosis for Permanent Impairment

The claims administrator needs information on how likely permanent impairment is as a result of the injury. This helps determine long-term benefits.

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Claims Administrator as a Resource

A claim administrator is an important resource for physicians who have questions about specific workers' compensation requirements, such as filing procedures or benefit limits.

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Medical Goods and Services

These are the services and goods required to treat the injured worker's injuries. This may include physical therapy, X-rays, medications, and assistive devices.

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Physicians in Workers' Compensation

These professionals play a crucial role in the workers' compensation process by assessing the worker's injuries, creating treatment plans, and providing reports to support the claim.

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Attorneys in Workers' Compensation

Attorneys can represent any party involved in a workers' compensation claim, including the injured worker, employers, or providers seeking payment for services rendered.

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Employer Termination During Disability

An employer cannot terminate an injured worker during their temporary disability period without a valid reason. The employer must prove that the termination was due to a 'business necessity.'

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Reinstating Injured Workers

An employee is protected from discrimination based on their involvement in workers’ compensation claims. Employers cannot refuse to reinstate an injured worker unless there are valid reasons like medical limitations or essential job function changes.

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Discrimination and Disabilities

The Americans with Disabilities Act and the California Fair Employment and Housing Act address the employer's responsibility to accommodate employees with disabilities. These laws aim to prevent discrimination by employers against employees with disabilities.

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Insurer's Role in Workers' Compensation

In the workers’ compensation system, the insurance company assumes most of the liability for the insured employer. They are responsible for paying benefits, handling medical records, and reimbursing medical expenses.

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Insurer's Liability in Workers' Compensation

Insurers are responsible for paying benefits, managing medical records and expenses, and taking care of the majority of the claims process. Some penalties, like those related to severe employer misconduct, are not their responsibility.

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Claims Administrator's Role

Claims administrators are key personnel in workers' compensation. They analyze physician reports, assess the severity of injuries, and make decisions about benefit payouts.

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Self-Insured Employers

Self-insured employers can chose to manage their own claims or hire external companies called 'third-party administrators' (TPAs).

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Medical Case Managers

Medical case managers play an important role in helping injured workers return to work. They coordinate medical care, communicate with employees, and understand job requirements.

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Bill Review

The process of examining medical bills and procedures to ensure they are appropriate and necessary for the worker's injury.

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Utilization Review

A process that evaluates medical services to determine if they are needed and appropriate for the worker's condition.

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Liability Determination

The determination of whether an injury occurred at work and is therefore covered by workers' compensation.

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Workers' Compensation Benefits

Payments made to injured workers to compensate for lost wages, medical expenses, and other related costs.

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Compensation, Medical, & Supplemental Job Displacement Benefits

Benefits offered to workers during their recovery, including medical care, lost wages, and temporary assistance.

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Medical Treatment Approval

A review process to determine if a medical treatment request is appropriate, sometimes involving external experts.

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Claim Estimation

Accurate estimations of the expected costs associated with a workers' compensation case.

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Case Resume

A summary of the key information and actions taken in a workers' compensation case.

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Calculating and Negotiating Settlements

The process of negotiating and reaching a settlement agreement to resolve a workers' compensation claim.

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Applicant's Attorney

The lawyer representing the injured worker in a workers' compensation case.

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Workers' Compensation Judge

This judge decides the amount of the attorney's fees from the injured worker's compensation award.

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Attorney Fees

A percentage of an injured worker's compensation award that is paid to their lawyer for representing them.

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Permanent Disability

This type of disability payment is awarded if the worker's injury is permanent.

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Hearing Representative

A type of representative who can help injured workers with their case, but cannot receive attorney fees.

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Who is covered by California workers' compensation?

The California workers' compensation system covers most employees, including farm workers, domestic workers, and some state prison inmates.

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Who is NOT covered by the California workers' compensation system?

A federal, maritime, or railroad employee's work-related injury is covered under a separate system.

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How long does an employee have to report a work injury?

An employee must inform their employer about a work-related injury or illness within 30 days of the incident.

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What is the employer's role in reporting a work injury?

The employer is required to provide the employee with a claim form (DWC 1) within one working day of learning about the injury.

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Can an employee choose their own doctor?

An employee can predesignate a personal physician for treatment in case of a work-related injury or illness.

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What are the options for choosing a chiropractor or acupuncturist?

If the employer or insurer doesn't have an MPN, employees can choose their personal chiropractor or acupuncturist after the initial 30 days.

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Who has control over the treating physician in the first 30 days?

After the initial 30 days, the claims administrator can select the treating physician, but the employee may then transfer to their personal chiropractor or acupuncturist.

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How many chiropractic visits are allowed without employer authorization?

After 24 chiropractic visits, the employer must authorize any additional visits in writing.

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What is a DWC 1 form?

A claim form is a document used to formally start the workers’ compensation process.

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What is an MPN?

An MPN (Medical Provider Network) is a list of healthcare providers that employers and insurers have contracted with for workers' compensation claims.

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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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Related Documents

California Workers' Compensation Chapter 4 PDF

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.

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