Worker's Compensation Terminology & Acronyms PDF

Terminology & Acronyms General + Specific information for VA 1 Part 1: Terminology (general) 2  Part A WORKER’S COMPENSATION (WC) INDUSTRY TERMS 3  WORKER’S...

Terminology & Acronyms General + Specific information for VA 1 Part 1: Terminology (general) 2  Part A WORKER’S COMPENSATION (WC) INDUSTRY TERMS 3  WORKER’S COMPENSATION (WC) INDUSTRY TERMS Arising out of employment: An accident arises out of the employment if the employee was engaged about his employer's business at the time of the accident, and the necessities of the employer's business required that he be at the place of the accident at the time the accident occur Average Weekly Wage (AWW) An employee's pre-injury earning capacity, based on earnings in the period directly preceding a work-related injury or illness. Claimant = Injured Worker, or the person filing the WC claim Date of Injury (DOI) If the injury was caused by one event (a specific injury), this is the date of the event. If the injury was caused by repeated exposures (a cumulative injury), this is the date that the worker knew or should have known that the injury was caused by work. Denied Claim When an insurance carrier refuses to cover a WC claim Dispute Resolution A process to resolve disagreements about elements of a WC claim Disputed claim When an insurance carrier decides that a claim isn't valid, they can dispute (or challenge) a WC claim. This can take many different forms, depending on the WC system Division of WC A state agency that is charged with administering the WC system within a state Fee Schedule The maximum allowable rate a medical provider is allowed to charge for a specific medical service Impairment guidelines Impairment is a problem that affects the functioning of a part of the body and makes someone unable to use their body the same way they did before the accident or injury. It can include physical impairments or mental impairments caused by injury or illness. Impairments can be permanent or temporary, severe or mild. Impairment Rating Impairment rating is a percentage estimate of the amount of normal use that your injured body parts have lost, which is based on guidelines that have been published by the American Medical Association (AMA). 4  WORKER’S COMPENSATION (WC) INDUSTRY TERMS (CONTINUED) Insurance Carrier Could be an insurance company, a certified self-insurer, a certified self-insurance group, or a government entity that self- insures. An insurance carrier contracts with an employer to provide medical and income benefits to an injured employee if they are hurt or get sick Maximum Medical Improvement (MMI) When no further healing or recovery from an injury can be expected. Medical Treatment Guidelines A set of evidence-based medical care/guidance that attempts to summarize the best treatment medical practices for an injured worker's particular injuries. The most prominent example of a medical treatment guidelines is ODG (by MCG). ODG stands for Official Disability Guidelines, and it serves as the default treatment guidelines for several states across the country Modified Job Duty/Mod Work Modified work means that your employer makes changes to your duties or your workplace because your injury prevents you from doing some parts of your regular job. Nurse Case Manager A nurse, hired by an insurance carrier or TPA who is certified by the State Board of Nursing to provide case management services, including but not limited to interviewing the worker for the purpose of implementing and coordinating services with health care providers and with the worker and the worker's family. Permanent Disability Permanent disability (PD) is any lasting disability from your work injury or illness that affects your ability to earn a living. If your injury or illness results in PD you are entitled to PD benefits, even if you can go back to work Return to work (RTW) A Return-to-Work program is a process for allowing injured, ill, or disabled workers to return to their job duties as soon as they are able, as defined by their physician. Self-Insured A self-insured Workers' Compensation plan (or a self-funded plan as it is also called) is one in which the employer assumes the financial risk for providing Workers' Compensation benefits to its employees. 5  WORKER’S COMPENSATION (WC) INDUSTRY TERMS (CONTINUED) State fund Workers' compensation state insurance funds are government-funded organizations that provide workers' comp insurance to employers and employees in a specific state. Temporary Disability Temporary disability (TD) benefits are payments you get if you lose wages because your injury prevents you from doing your usual job while recovering. Third Party Administrator (TPA) A company that collects insurance premiums, contributions, or adjusts claims for an insurance carrier. Total Disability Total permanent disability (TPD) is a condition in which an individual is no longer able to work due to injuries. Total permanent disability, also called permanent total disability, applies to cases in which the individual may never be able to work again. Treating Doctor/Doctor of record A medical provider that is authorized to treat an injured worker Utilization Review (UR) A legal mechanism/action typically used by an insurance carrier/TPA to review medical care. Generally, this involves hiring a medical provider to examine an injured worker's medical records (AKA a peer review or chart review) or to conduct physical examination of a patient (AKA an IME or RME) 6  PART B MEDICAL INDUSTRY & MEDICAL OFFICE TERMS 7  MEDICAL INDUSTRY & MEDICAL OFFICE TERMS American Medical Association (AMA) Impairment Ratings Currently on the sixth edition of the Guides to the Evaluation of Permanent Impairment, published by the American Medical Association (AMA), defines impairment as "a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder, or disease. Different states use different ediditions of these guidelines to apportion additional WC benefits to an injured worker Balance billing When a doctor or hospital bills the injured employee for the difference between what they were charged for services and the amount insurance paid. For example, if the medical fee is $100 and insurance only pays $70, a provider may try to bill an injured employee for the remaining $30. Many state systems DO NOT allow this practice, at least until the claim has been finalized in the state WC system as a non WC claim Controlled Substances Controlled substances are drugs that have the potential for abuse, misuse, and dependence. The lower the drug schedule, the higher the risk of harm for a patient. Demographics Patient information sheet, includes things like name, Social security #, address, phone number, etc. Also called a “face sheet” EPCS Electronic prescribing of controlled substances, or EPCS, is the process of electronically transmitting prescriptions for controlled substances to the pharmacy Face Sheet: Patient information sheet, includes things like name, Social security #, address, phone number, etc. Also called an “intake form” Future medicals (future meds) Employers are typically responsible for payment of medical expenses associated with their employees’ on-the-job injuries. Medical benefits are often lifetime benefits if the medical expenses are related to the underlying job injury. In some states, the employee’s right to future meds can be terminated when the employee and employer agree to the terms and a judge or appropriate administrative authority approves the agreement. 8  MEDICAL INDUSTRY & MEDICAL OFFICE TERMS (CONTINUED) OccuScript A private PBM that Concentra has a substantial ownership interest in; Also the pharmacy system Concentra uses in-house currently Nurse Practitioner (NP) Also known as an FNP. A medical provider that is A nurse practitioner (NP) is a nurse with a graduate degree in advanced practice nursing. This type of provider may also be referred to as an ARNP (Advanced Registered Nurse Practitioner) or APRN (Advanced Practice Registered Nurse). Also referred to as a “mid level”. Opioid A substance used to treat moderate to severe pain. Opioids are like opiates, such as morphine and codeine, but are not made from opium. Opioids bind to opioid receptors in the central nervous system. Opioids used to be called narcotics. An opioid is a type of alkaloid. Physician Assistant (PA) A physician assistant (PA) is a licensed medical professional who holds an advanced degree and is able to provide direct patient care. Also referred to as a “mid level”. Pre-existing condition A pre-existing condition is a health issue that required diagnosis or treatment prior to an applicants’ enrollment in a health plan Prescription Monitoring Program or Prescription Drug Monitoring Program (PMP or PDMP) An electronic database that tracks controlled substance prescriptions in a state. Scheduled medications Drugs are regulated by the federal Controlled Substance Act (CSA) to protect public health and safety. The CSA divides controlled substances into five categories, known as schedules. They are assigned specific schedules based on whether they have a currently accepted medical use in the United States, their relative potential for abuse, and the risk of causing dependence if they are abused. SureScripts An information technology company that supports e-prescription, the electronic transmission of prescriptions between health care organizations and pharmacies, as well as general health information exchange (HIE) of medical records their work tasks. Work hardening is multidisciplinary, using a physical therapist, occupational therapist, psychologist and vocational specialist. 9  MEDICAL INDUSTRY & MEDICAL OFFICE TERMS (CONTINUED) Vocational Rehabilitation (VR) Vocational rehabilitation generally includes a variety of services that are offered to injured employees to help them return to work following a work injury. Vocational rehabilitation may involve transferable skills assessments, educational courses, job search assistance, and many other vocational aids. Vocational rehabilitation is sometimes referred to as “occupational rehabilitation.” Work Conditioning Work conditioning is a rigorous conditioning program designed to help patients regain their systemic, neurological, cardiopulmonary and musculoskeletal functions. This includes strength, mobility, power, endurance, motor control and functional abilities. Work Hardening Work hardening is an individualized, highly-structured program designed to help patients return to their pre-injury work level in a safe and timely manner. It aims to help patients regain their biomechanical, cardiovascular, metabolic, neuromuscular and psychosocial functions in conjunction with 10  PART C LEGAL & LAW FIRM TERMS 11  LEGAL & LAW FIRM TERMS Administrative Hearing An administrative hearing is the "trial" phase of the resolution of a disputed workers' compensation claim issue or possibly even the case in full. Rules of evidence may or may not apply, depending on the jurisdiction Attorney One whose profession is to conduct lawsuits for clients or to advise as to legal rights and obligations in other matters. Also known as a "lawyer" Case Law The law as established by the outcome of former cases in a system's court system Compensable A compensable claim is a claim covered under the Workers Compensation Act Expert witness A person who, because of education, training, or experience, has special knowledge of a subject that the average person does not Holiday If an insurance carrier overpays or another source of payment is “on the hook”, sometimes the carrier is entitled to not pay benefits for a defined time period Indemnification Compensation for harm or loss Lawyer One whose profession is to conduct lawsuits for clients or to advise as to legal rights and obligations in other matters. Also known as a "attorney" Legal Assistant A person trained in subsidiary legal matters but not fully qualified as a lawyer. Often the attorney's "right-hand" person in the law firm. See also "paralegal" Letter of Protection (LOP) A legally binding document between an injury victim, their personal injury attorney, and their medical provider that guarantees payment for medical expenses. Also known as a "lien letter" in some jurisdictions LexisNexis A privately published legal research database/set of research tools used by attorneys. See also LexisNexis Mediation A process wherein the parties meet with a mutually selected impartial and neutral person who assists them in the negotiation of their differences. 12  LEGAL & LAW FIRM TERMS (CONTINUED) Medicare set-aside agreement (MSA) When a workers’ comp case is settled to include the closing of future meds and the claimant is a Medicare beneficiary or is expected to become one soon, money for projected medical expenses associated with the injury may be “set aside” in a bank account as part of the settlement. These funds are used solely to pay for medical expenses related to the injury that would otherwise be paid by the employer. Office manager An office manager is a person who is responsible for the administrative activities of a company or organization. Also known as an "attorney" Paralegal A person trained in subsidiary legal matters but not fully qualified as a lawyer. Often the attorney's "right-hand" person in the law firm. See also "legal assistant" Regulation A law, rule, or other order prescribed by authority, especially to regulate conduct. These rules often clarify law passed through legislation, A written law passed by a legislative body, signed by a governor (in most cases, anyway) and are formulated through a rule-making process Statute A written law passed by a legislative body, signed by a governor (in most cases, anyway) Statute of limitations (SOL) An injury/accident, usually involving an auto accident while an employee was driving a company owned car that has two components. Third-Party Claim A claim made by an injured third party (as a third-party beneficiary of workers' compensation insurance) against an insurer or insured for indemnification. The first party claim is a WC claim. The third party claim is against the person that caused the injury. For example, you are driving and another driver rear-ends you. You would likely have a WC claim + a 3rd party claim (a personal injury claim against the other car's driver). Sometimes these are handled by the same law firm, sometimes different law firms handle each claim & sometimes only one side of the claim is represented Westlaw A privately published legal research database/set of research tools used by attorneys. See also LexisNexis 13  PART D PHARMACY RELATED TERMS 14  PHARMACY RELATED TERMS Adjudicate A term used in the insurance industry to refer to the process of paying claims submitted or denying them after comparing claims to the benefit or coverage requirements Average Wholesale Price (AWP) A benchmark used for pricing and reimbursement of prescription drugs for both government and private payers Fee Schedule A listing of the fees normally charged by a given health care provider for specific therapies and procedures provided. For pharmacies, the relevant pricing term is AWP First Fill Program A PBM program that typically will cover the first 10-30 days of a WC Patient’s medications- but ONLY after the claim is verified to be open and compensable. Letter of Medical Necessity (LOMN) A letter of medical necessity (LOMN) is a letter issued by a person's physician describing why a requested treatment is necessary. LOMNs are often used to justify a request for specific medications, medical equipment, or therapy 15  PHARMACY RELATED TERMS Pharmacy Benefit Manager (PBM) A group of companies that serve as the middlemen between insurance companies, pharmacies, and drug manufacturers. PBMs are responsible for securing lower drug costs for insurers and insurance companies. They accomplish this by negotiating with pharmacies and drug manufacturers. The discounts are then passed onto insurance companies. Profits are generated through the slight up- charging of drugs or retaining portions of rebates. Prior Authorization (AKA Pre-Auth) Prior authorization (prior auth, or PA) is a management process used by insurance companies to determine if a prescribed product or service will be covered Re-Adjudicate Attempting to re-process a denied pharmacy bill Transfer A prescription transfer is when you decide to move your prescriptions from one pharmacy to another 16  PART E INTERNAL (EZ SCRIPTS) TERMS 17  INTERNAL (EZ SCRIPTS) TERMS Concur Our new expense reimbursement software EZ Scripts University A section within our internal SharePoint AKA where all industry information lives MOTUS A mileage tracker = our internal expense reimbursement software. Marketing Collateral Materials made for marketing EZ Scripts New Patient Shipped (NPS) A patient that uses EZ Scripts pharmacy for the first time Referral meeting A meeting with a new/potential referral source in which expectations are made clear, specific targets/goals for referral are set, and a follow-up meeting is set BEFORE LEAVING THE REFERRAL MEETING Salesforce Our internal CRM SharePoint Where everything "lives". AKA our internal document repository. Welcome Packet A packet of information sent to a new patient 18 Part 2: Acronyms (General) 19  PART A WC INDUSTRY ACRONYMS 20  WC INDUSTRY ACRONYMS All sections are in alpha order. AWW Average weekly wage PTD Permanent total disability DOI Date of Injury RME Required medical exam FCE Functional Capacity Evaluation RTW Return to work FROI First report of injury SIF Second or Second Injury Fund IME Independent Medical Examination TD Temporary Disability IR Impairment rating TPD Temporary partial disability IR Impairment Rating TTD Temporary total disability IW Injured Worker UR Utilization Review MMI Maximum Medical Improvement WC Workers’ Compensation NCM Nurse Case Manager WCRI Workers’ Compensation Research Institute PD Permanent disability PPD Permanent partial disability 21  PART B INTERNAL (EZ SCRIPTS) ACRONYMS 22 INTERNAL (EZ SCRIPTS) ACRONYMS CS Customer Service EZRx EZ Scripts Pharmacy KPI Key Performance Indicator PPS Preferred Pharmacy Form PrimeRx Ez Scripts' pharmacy software RS Referral Source SF Salesforce SP SharePoint 23  PART C MEDICAL ACRONYMS 24  MEDICAL ACRONYMS All sections are in alpha order. CARF Commission on Accreditation of Rehabilitation Facilities CDC U.S. Centers for Disease Control and Prevention CI-CVI Controlled Substance Ratings DME Durable Medical Equipment DO Doctor of Osteopathy Dx Diagnosis EHR Electronic Health Record EMR Electronic Medical Record (Escribe) 25  MEDICAL ACRONYMS (continued) All sections are in alpha order. FDA Federal food & drug Administration Fx Fracture HCFA Health Care Financing Administration HIPPA Health Insurance Portability & Accountability Act LBP Lower Back Pain NP Nurse Practitioner OV Office Visit PA Physician’s Assistant PCP Primary Care Physician PT Physical Therapy ROM Range of motion 26  PART D LEGAL ACRONYMS 27  LEGAL ACRONYMS All sections are in alpha order. ADR Alternative Dispute Resolution ALJ Administrative law judge IF Intake Form LOMN Letter of Medical Necessity LOP Letter of Protection MSA Medicare Set Aside MVA Motor Vehicle Accident PI Personal injury SOL Statute of limitations SSD Social Security Disability 28  PART E PHARMACY ACRONYMS 29  PHARMACY ACRONYMS All sections are in alpha order. a.c. before Meals a.q. Water; as in take with water b.i.d. Twice Daily DAW Dispense as written d.c. Discontinue Et and h.s. at bedtime ID intradermal; as in administered intradermally or through the skin IM Intramuscular IN intranasal; as in administered intranasally or through the nose Inj. Injection IV Intravenous OTC Over-the-Counter Max. Maximum Min. Minimum 30  PHARMACY ACRONYMS All sections are in alpha order. p.c. after meals p.o. By mouth Prn As needed PBM Pharmacy Benefit Manager q Every (example: q12 = every 12 hours) q.o.d. every other day q.a.m. every morning q. d. every day q.h.s. every bedtime q.i.d. four times a day q.p.m. Every evening Rx Prescription s. without TPA Third Party Administrator w. with 31  The End (of general discussion) The next portion of this presentation will focus on Maryland 32 Addendum #1- State Specific Terms Virginia 33  VIRGINIA SPECIFIC TERMS 20-Day Order Payments Made: An official court document that is generated when the Claim Administrator reports payments to the Commission; the Claim Administrator has 20 days to respond. This document is generated when the total medical expenses paid exceeds $3,500, no Award has been entered, and if wage loss is paid and the Commission has no matching Award on file. 30-Day Order Claim Filed: An official court document that directs the Claim Administrator, Insurance Carrier and/or Designated Representative to respond to an injured worker’s claim form within 30 days. The Claim Administrator, Insurance Carrier and/or Designated Representative may either accept or deny the claim. 90-Day Rule: See Change in Condition. 500-weeks: The maximum number of weeks an injured worker can receive compensation, except in cases of permanent and total incapacity and certain occupational diseases. Alternative Dispute Resolution: A way for parties to resolve disputes without the need for a hearing. This term also refers to mediation. Mediation is a voluntary and confidential informal dispute resolution process where a neutral third party (mediator) facilitates communication to assist the parties in mediating an agreeable solution. The purpose of mediation is to identify issues, clarify misunderstandings, explore solutions and mediate an agreement. Any party to a claim may request mediation to resolve a dispute quickly or to negotiate the compromise settlement of a claim. An injured worker does not have to be represented by an attorney unless they wish to mediate a compromise settlement. American Medical Association (AMA): A national physician's group. The AMA publishes a set of guidelines called "Guides to the Evaluation of Permanent Impairment." A physician may determine your level of impairment using the AMA's guides. Amputation Chart (Form 7): A form completed by a physician to show the point of amputation. 34  VIRGINIA SPECIFIC TERMS (CONTINUED) Appeal: To ask a higher court to review a decision. Assertion of Rights: This is also known as a protective filing. Assertion of Rights means that an injured worker wishes to protect their rights but request no action be taken on the claim at the present time. Attending Physician’s Report (Form 6): A form completed by the attending physician that describes the nature and extent of an injury. The use of this form is optional. Average Weekly Wage (AWW): The earnings of the injured worker in the employment in which they were working at the time of the injury. This is usually calculated by adding the wages of the worker for the 52 weeks prior to the injury, divided by 52. Award: The grant or denial of benefits or other relief under The Virginia Worker’s Compensation Act. Award Order: See Award. Award Agreement (Agreement to Pay Benefits – Form #CSD-50): This form is completed by the Claim Administrator whenever a claim has been accepted as compensable and the injured worker is entitled to an award. The Award Agreement provides the basis for the award of compensation. Benefits Covered under the Act: The following benefits are covered under the Workers’ Compensation Act: wage replacement, lifetime medical benefits, permanent partial impairment, permanent and total disability, death benefits, cost of living increase, and vocational rehabilitation. 35  VIRGINIA SPECIFIC TERMS (CONTINUED) Burden of Proof: The legal requirement of a party to prove a fact by a standard of evidence. For example, the injured worker is required to prove by a “preponderance of evidence” that they suffered an injury by accident which arose out of and in the course of employment. Bureau of Insurance: The Bureau shares in dual regulation of workers’ compensation insurance in Virginia with the Workers’ Compensation Commission. The Property and Casualty Market Regulation Division monitors the market activities of companies and agents within the Property and Casualty classes of insurance. Their responsibilities include regulating the insurance rates and underwriting, performing insurance investigations, and resolving complaints about agents, agencies and insurance carriers. Carrier: See Insurance Carrier. Cease and Desist: The Commission may order an employer to Cease and Desist all business transactions and operations in Virginia upon a finding that the employer failed to insure when required by the Act. Change in Condition: A change in physical condition of the injured worker, as well as any change in the conditions under which compensation was awarded, suspended, or terminated which would affect the right to, amount of, or duration of compensation. A change in condition claim must be in writing and state the change relied upon. A copy of the claim should be sent to the employer. Additional compensation may not normally be awarded more than 90 days before the filing of the claim with the Commission. COLA benefits are not subject to this limitation. 36  VIRGINIA SPECIFIC TERMS (CONTINUED) Claim Form: This form is completed by an injured worker to either assert their rights or request benefits. The injured worker must file a claim with the Virginia Workers’ Compensation Commission within two years from the date of injury, in most cases (certain statutes pursuant to Code Section 65.2 may toll the statute of limitations). In most cases of occupational diseases, a claim must be filed within two years from the date the doctor tells you the disease is work related, or five years from the date you were last exposed to the work condition causing the disease, whichever is sooner. Certain diseases have different limitation periods. Claimant: See Injured Worker. Claim Adjuster: The individual at the Claim Administrator that has been assigned to handle a particular workers' compensation claim. Claim Administrator: A Claim Administrator is the organization responsible for administering workers' compensation claims. This may include paying compensation if ordered, submitting the required EDI transactions, and sometimes scheduling medical appointments. A Claim Administrator can either be a self- administered insurance carrier, self-administered self-insured employer, or a third-party administrator hired by an insurance company or self-insured employer to handle their workers' compensation claims. Claim Administrator Claim Number: An internal filing number assigned by the insurance carrier to the file of an injured worker. This number is different from the Commission’s Jurisdiction Claim Number (JCN). Claim Examiner: See Claim Adjuster. Commission: See Virginia Workers’ Compensation Commission. Commissioners: The Commission is headed by three Commissioners. The Commissioners are chosen by the General Assembly and serve six-year terms. The Commissioners are also appointed to review and reconsider decisions of Deputy Commissioners. 37  VIRGINIA SPECIFIC TERMS (CONTINUED) Compensable Claim: A claim in which the Claim Administrator and/or Insurance Carrier agrees or the Commission finds that an injury or occupational disease arose out of and in the course of employment and is covered under the Virginia Workers’ Compensation Act (Code Section 65.2). Compensation Rate: The weekly amount of compensation to which the injured worker is entitled by an award from the Commission. For temporary total, permanent total, and permanent partial disability benefits, the compensation rate is calculated by multiplying the injured worker’s pre-injury gross average weekly wage by.66667. When the injured worker is working but earning less than the pre-injury average weekly wage, the compensation rate is calculated by taking the difference between the injured worker’s pre-injury average weekly wage and the current weekly wage, and multiplying that amount by.66667. Compromise Settlement: A type of settlement in which an injured worker receives a lump sum payment and may become responsible for paying for future medical expenses. The Commission does not negotiate settlements. This type of settlement has to be approved/disapproved by a Deputy Commissioner. This is also known as a Petition and Order. Cost of Living Adjustment (COLA): If an injured worker is receiving temporary total, permanent total, or death benefits they are entitled to a cost of living increase effective October 1st of each year if the date of accident is prior to July 1st of that year and if the combination of compensation and Social Security benefits are less than 80% of the pre-injury earnings. Cost of living increases must be specifically requested by the injured worker. 38 Counsel: See Defense Counsel or Injured Worker’s Counsel.  VIRGINIA SPECIFIC TERMS (CONTINUED) Court of Appeals of Virginia: An 11-judge body that hears appeals from decisions of Virginia’s circuit courts and the Virginia Workers’ Compensation Commission. Criminal Injuries Compensation Fund (CICF): See Virginia Victims Fund (VVF). Date of Accident: See Date of Injury. Date of Injury: The date an injured worker was injured or exposed or diagnosed with an occupational disease. The injured worker must file a claim with the Virginia Workers’ Compensation Commission within two years from the date of injury, in most cases (certain statutes pursuant to Code Section 65.2 may toll the statute of limitations). In most cases of occupational diseases, a claim must be filed within two years from the date a doctor determines the disease is work related, or five years from the date last exposed to the work condition causing the disease, whichever is sooner. Certain diseases have different limitation periods. Death Benefits: A surviving spouse, children under 18, children under 23 enrolled full-time in an accredited educational institution, parents in destitute circumstances or other qualifying dependents may be entitled to wage loss benefits. Death benefits include funeral expenses not to exceed $10,000 and transportation cost of $1,000. Decision: See Judicial Opinion. Defendant: The party – typically the employer, claim administrator, or insurance carrier – opposing an injured worker in a dispute over benefits or services. Defense Counsel (PD): The attorney(s) representing the employer, claim administrator, and/or insurance carrier. 39  VIRGINIA SPECIFIC TERMS (CONTINUED) Denied Claim: A claim in which the Claim Administrator and/or Insurance Carrier disagrees that an injury or occupational disease arose out of and in the course of employment and is covered under the Virginia Workers’ Compensation Act (Code Section 65.2). An injured worker may appeal a denial by requesting a hearing in writing or by using the Claim Form. Deputy Commissioner: An employee of the Commission who makes decisions relating to Virginia workers’ compensation disputes. Deputy Commissioners conduct evidentiary hearings, on-the-record hearings, and approve or disapprove compromise settlements. The decision of a Deputy Commissioner can be appealed by requesting a Review to the Full Commission. Disability Rating: See Permanent Partial Disability Rating. Discovery: The fact finding process that may take place after a claim has been filed. Discovery may be obtained by oral or written deposition, interrogatories to parties, production of documents or things, requests for admission, inspection of premises or other means of inquiry approved by the Commission. Certain rules apply concerning this process. Dispute: A disagreement between an injured worker and Claim Administrator about the right to payments, services or other benefits. Dismissed with Prejudice: The plaintiff or injured worker is barred from bringing an action on the same claim. Dismissed without Prejudice: The plaintiff or injured worker may file a new suit on the same claim within the statute of limitations. Docket: A calendar of the cases that have been scheduled for a hearing and pending determination. Docketed: A case is docketed if it has been referred for a hearing and placed on a Deputy Commissioner’s docket. The Deputy Commissioner’s office schedules the case for a hearing and notifies the parties of the date, time, and location of the hearing. 40  VIRGINIA SPECIFIC TERMS (CONTINUED) Electronic Data Interchange (EDI): The method used to exchange data electronically between the Commission and those organizations submitting claim reports to the Commission. The International Association of Industrial Accident Boards and Commissions (IAIABC) is the international organization that developed and implemented the EDI Standard for Workers’ Compensation claims reporting that is used by the Commission today. Virginia has selected and implemented the IAIABC Release 3 format for EDI reporting of Workers' Compensation claims information. Employee: Every person, including aliens and minors, in the service of another under any contract of hire or apprenticeship, written or implied, where lawfully or unlawfully employed. Note: Virginia law exempts some workers from being considered employees under the Workers’ Compensation Act. In particular, employees of an employer that has regularly in service less than three employees in Virginia, is not considered an employee under the Act, unless the employer voluntarily elects to cover such employees. Employer: The person or entity with control over employees work activities. Employer’s Application for Hearing (Form 5A): This form is used by the self-insured employer, insurance carrier, claim administrator or their legal counsel to complete and submit to the Commission along with the required documentary evidence in order to suspend or terminate an injured worker’s compensation benefits under an existing Award of the Commission based upon a change in condition. In addition, this form may be used to request other relief from the Commission. Employment Marketing: See Light Duty Restrictions. Evidentiary Hearing: See Hearings. 41  VIRGINIA SPECIFIC TERMS (CONTINUED) Executive Officer: Means (i) the president, vice-president, secretary, treasurer or other officer, elected or appointed in accordance with the charter and bylaws of a corporation and (ii) the managers elected or appointed in accordance with the articles of organization or operating agreement of a limited liability company. However, such term does not include non-compensated officers of corporations exempt from taxation pursuant to § 501(c)(3) of Title 26 of the United States Code (Internal Revenue Code of 1954). Expedited Hearing: An expedited hearing may be requested if the employer’s denial of benefits, after initial compensability has been established, will cause the injured worker to incur severe economic hardship. An injured worker seeking an expedited hearing must file with the Commission an Expedited Hearing Request Form along with supporting documentation (the form is available on the Commission’s website). Family and Medical Leave Act (FMLA): The FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. For more information, contact the U.S. Department of Labor, Wage and Hour Division at 866-487-9243. Fee Schedule: See Medical Fee Schedules. Filed: Means hand delivered to the Commission's headquarters in Richmond or any regional office maintained by the Commission; sent by means of electronic transmission approved by the Commission; sent by facsimile transmission; or posted at any post office of the United States Postal Service by certified or registered mail. Filing by first-class mail, electronic transmission, or facsimile transmission shall be deemed completed only when the document or other material transmitted reaches the Commission or its designated agent. The Commission does not accept filings by email. 42  VIRGINIA SPECIFIC TERMS (CONTINUED) Filing: Sending or delivering a document. The date of filing is the date the document was received or the postmark date of Certified Mail. The Commission does not accept filings by email. First Report of Injury (FROI): The initial claims report filed with the Commission by or on behalf of the insurance carrier or self-insurer concerning an injury. A FROI is also a method to report a denial, a change of information previously reported via EDI, a Claim Administrator acquisition, and a cancelation of a claim. Fraud: As it relates to worker’s compensation, fraud occurs when an employee claims to have suffered an injury while on the job and either did not suffer an injury at all, or received the injury while doing something non-work-related. The Commission does not investigate cases of fraud; these cases are investigated by the Virginia State Police. They can be reached at 877-623-7283. Employers can also commit worker’s compensation fraud by understating the number of employees or the type of work they do. Anyone can report potential employee misclassification and non-compliance with the Virginia Workers’ Compensation Act through VENCA (Virginia Employer Non-Compliance Alerts) at www.vencalerts.com. For more information, contact 804-205-3586 or [email protected]. Full and Final Mediation (FFM): A form of mediation where parties wish to mediate a Compromise Settlement. Also see Alternative Dispute Resolution. Functional Capacity Evaluation (FCE): The Functional Capacity Evaluation is a comprehensive series of performance-based tests that help objectively measure injured workers’ physical abilities. The tests gauge physical strength, range of motion, stamina and tolerance of functional activities. Health Care Provider: An individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities. 43  VIRGINIA SPECIFIC TERMS (CONTINUED) Hearing: Legal proceedings in which a Deputy Commissioner discusses the issues in a case or receives information in order to decide about a dispute or a proposed settlement. There are two types of hearings: Evidentiary and On-the-Record. An Evidentiary hearing is a hearing in which the parties personally appear before a Deputy Commissioner. Testimony is taken under oath and witnesses can be cross-examined. An On-the- Record hearing is a hearing in which there is no material fact in dispute as to any contested issue. The parties do not personally appear before a Deputy Commissioner. After each party has been given the opportunity to file a position statement of the evidence supporting a claim or defense, the Commission enters a decision on the record. Hearing Location: See Venue. Impairment Rating: A percentage estimate to determine the loss or loss of use to an extremity. Impairment ratings are usually determined based on guidelines published by the American Medical Association (AMA). The Commission cannot process a claim for permanency benefits until a statement of maximum medical improvement and physician’s rating is received. Ratings involving disfigurements and scarring are determined by the Commission. Indemnity: Reimbursement/compensation for loss. Independent Contractor: Under the Virginia Workers’ Compensation Act, an employee is a person who is under written or implied contract of hire "except one whose employment is not in the usual course of the trade, business, occupation or profession of the employer." In distinguishing between an employee and an independent contractor, some important considerations are (1) the right to hire, (2) the power to dismiss, (3) the obligation to pay wages, and, most importantly (4) the power to control the means and methods by which the work is done. 44  VIRGINIA SPECIFIC TERMS (CONTINUED) Independent Medical Evaluation: The Commission may appoint a disinterested physician or surgeon to make a necessary medical examination. This authority is exercised to help the Commission resolve a conflict in the medical opinions or to prevent a perpetration of fraud on the Commission. The employer or insurance carrier may also require an injured worker to submit to an Independent Medical Examination. However, no employer may obtain more than one examination per medical specialty without prior authorization from the Commission, based upon a showing of good cause or necessity. Injured Worker: The party who sustained an injury or occupational disease on the job. The injured worker must file a claim with the Virginia Workers’ Compensation Commission within two years from the date of injury, in most cases (certain statutes pursuant to Code Section 65.2 may toll the statute of limitations). In most cases of occupational diseases, a claim must be filed within two years from the date the doctor tells you the disease is work related, or five years from the date you were last exposed to the work condition causing the disease, whichever is sooner. Certain diseases have different limitation periods. Once a claim is filed, the injured worker is known as a Claimant. Injured Worker’s Counsel (PQ): The attorney(s) representing an injured worker. The injured worker is not required to have an attorney. Insurance Carrier: A company licensed to write workers’ compensation coverage in Virginia. Judge: See Commissioner and Deputy Commissioner. Judicial Opinion: A written decision issued by a Deputy Commissioner within a few weeks of the hearing. If a party disagrees with the decision, they can appeal to the Full Commission. 45  VIRGINIA SPECIFIC TERMS (CONTINUED) Jurisdiction Claim Number (JCN): This number is assigned to an injured worker when their claim is reported to the Commission. An injured worker is encouraged to include the JCN on any and all correspondences sent to the Commission. This number was formerly known as the VWC File Number. Examples of JCNs: VA00000123456, VA01002421234, VA02000001234, 123-34-56. Lien: A right or claim for payment against a workers’ compensation case. Lifetime Medical Benefits: Medical expenses for conditions caused by the accident or occupational disease are payable for as long as necessary, provided a claim was filed by the injured worker within the required time period and the expenses are reasonable and necessary. The injured worker is entitled to reimbursement for out-of-pocket medical expenses (prescriptions) and reasonable medical mileage. All medical bills should be sent to the Claim Administrator for payment. Light Duty Restrictions: The treating physician’s description of the work an injured worker can and cannot do. If an injured worker is released to return-to-work with light duty restrictions, they have a duty to reasonably market their residual work capacity. The guidelines on looking for light duty are available on the Commission’s website. Maximal Medical Improvement (MMI): An injury that is well stabilized and unlikely to change substantially, with or without medical treatment. Once an injured worker reaches MMI, a physician can assess how much, if any, permanent partial disability resulted from the work injury. Mediation: See Alternative Dispute Resolution. 46  VIRGINIA SPECIFIC TERMS (CONTINUED) Medical Fee Schedules: The Virginia Workers’ Compensation Medical Fee Schedules (MFS) outline maximum fees for health care providers, hospitals, and ambulatory surgical centers, rendering health care services to injured workers as provided in the Virginia Workers' Compensation Act. The MFS applies to healthcare services provided to an injured worker for any dates of service on or after January 1, 2018, regardless of the date of injury. Medical Only Award: An Award that provides lifetime medical benefits for reasonable, necessary, and authorized medical treatment causally related to the work- related injury; this Award does not provide wage replacement. If an injured worker has a claim for wage replacement, a claim must normally be filed within two years from the date of injury (certain statutes pursuant to Code Section 65.2 may toll the statute of limitations). This may also be known as Medical Benefits Only (MBO). Medical Provider Application: Health care providers play a vital role in the claim process. Accordingly, they have certain rights and remedies available to them under the Virginia Workers' Compensation Act. If a dispute arises as to reimbursement for a medical charge, the health care provider may file a claim or request mediation to resolve the dispute over payment of medical services rendered to an injured worker. Medical Treatment: Treatment reasonably required to cure or relieve the effects of a work-related injury or occupational disease. If an injured worker seeks treatment outside of their authorized treating physician, then they may be responsible for the payment of medical costs. Narrative Medical Records: A report written by a physician that describes the injured worker’s medical condition. Certain rules apply regarding the submission of medical records. 47  VIRGINIA SPECIFIC TERMS (CONTINUED) Notice: Every injured worker or their representative shall immediately on the occurrence of an accident or soon thereafter as practicable, give or cause to be given to the employer a written notice of the accident. The notice shall state the name and address of the injured worker, the time and place of the accident, and the nature and cause of the accident and injury. Notification of Injury: Once an injury is reported to the Commission, the Commission will notify the parties by sending the Notification of Injury letter. This document informs the parties of their rights and responsibilities. Occupational Disease: A disease arising out of, and in the course of employment, but not an ordinary disease of life to which the general public is exposed outside of the employment. Out-of-Pocket Expenses: See Lifetime Medical Benefits. Panel of Physicians: As long as necessary after an accident, the employer must provide, free of charge to the injured worker, a physician chosen by the injured worker from a panel of at least three physicians selected by the employer. The injured worker must select a doctor from the panel provided by the employer/insurance carrier. If a panel is not provided after notice of the injury, the injured worker may seek treatment from any physician. The treating physician may refer the injured worker to other physicians. Once treatment begins, the physician cannot be changed without approval of the employer/insurance carrier or after a hearing by the Commission. The employee must cooperate with medical treatment or the weekly benefits may be suspended. 48  VIRGINIA SPECIFIC TERMS (CONTINUED) Party: Parties to a claim include the injured worker, employer, insurance carrier, claim administrator, and attorneys of record for the injured worker, employer, or insurance carrier. Typically, family members are not considered a party to the claim unless the Commission has authorization from the injured worker. This may also include health care providers who have filed a claim, and their attorneys of record. Peer Review: Peer Review under Regulations of the Virginia Workers’ Compensation Commission (sections 16 VAC 30-60-10 through 16 VAC 30-60-140; 16 VAC 30-70-10 through 16 VAC 30-70-120) was repealed effective March 7, 2017. Permanent Partial Disability Benefits (PPD): Separate benefits are payable for the permanent loss of use of a body part such as an arm, leg, finger, or eye. Vision and hearing loss, as well as disfigurement may also be compensated. This does not include the back, neck or body as a whole. Benefits are for a specific number of weeks depending on the percentage of loss. The injured worker can receive these benefits while working if maximum medical improvement has been reached. Note: An injured worker cannot receive permanent partial and temporary total disability benefits at the same time. Permanent and Total Disability Benefits (PTD): Lifetime wage benefits may be payable if an injured worker loses both hands, arms, feet, legs, eyes, or any two in the same accident, or is paralyzed or disabled from a severe brain injury. This benefit is paid at the conclusion of a 500-week award for temporary total disability benefits. 49  VIRGINIA SPECIFIC TERMS (CONTINUED) Penalty: If an injured worker is awarded compensation and is not paid within two weeks after it becomes due, the injured worker may request a 20% penalty against the insurance carrier for untimely payments. The Commission shall assess a monetary penalty to an employer that fails to insure for workers’ compensation when required and for failing to make a report required by the Commission. The Commission also has the authority to issue a penalty to an insurance carrier, self-insurer, group self-insurance association, or third-party administrator for failure to make a report required by the Commission or to a professional employer organization for failure to comply with the Act. Other penalties are allowed under the Act. Not all are enumerated here. Petition and Order: See Compromise Settlement. Plaintiff: See Injured Worker. Pro se: An injured worker not represented by an attorney. Professional Employer Organization (PEO): Any person that enters into a written agreement with a client company to provide professional employer services. "Professional employer services" means services provided to a client company pursuant to a written agreement with a professional employer organization whereby the professional employer organization initially employs all or a majority of a client company's workforce and assumes responsibilities as an employer for all co-employees that are assigned, allocated, or shared by the agreement between the professional employer organization and the client company. A PEO is required to register with the Commission prior to transacting business in Virginia. 50  VIRGINIA SPECIFIC TERMS (CONTINUED) Proof of Coverage (POC): Each employer that is required to insure for workers’ compensation is required to provide evidence of compliance, known as proof of coverage. When the employer secures coverage through an insurance carrier the insurance carrier files coverage electronically with the Commission’s designated agent, NCCI. The Commission accepts as proof of coverage a Policy, Binder, Information Page or Declaration Page. Proof of Service: A form used to show that documents have been sent to specific parties. Rating: See Impairment Rating. Request for Benefits: See Claim Form. Request for Hearing: See Claim Form. Request for Review: An appeal to the Commissioners to review and reconsider a decision made by a Deputy Commissioner. Restrictions: See Work Restrictions. Return to Work (RTW): A release by the injured worker’s treating physician indicating they are able to return to work at the pre-injury wage or return to pre-injury work. Rules of the Virginia Workers’ Compensation Commission: There are thirteen Rules of the Commission. These rules are issued to provide procedures to identify and resolve disputed issues promptly through informal dispute resolution or hearing. Seven Day Waiting Period: Compensation is not allowed for the first seven calendar days of incapacity. If incapacity extends beyond the waiting period, then compensation will start on the eighth day of disability. If incapacity continues for a period of more than three weeks (21 days), then compensation is allowed from the first day of incapacity. 51  VIRGINIA SPECIFIC TERMS (CONTINUED) Show Cause: An order of the Commission directing an individual to appear on a certain date to show cause or explain why the Commission should not issue a specific order or make a certain finding. Example: to show cause why an employer with no workers’ compensation coverage should not be assessed a monetary penalty for failure to insure for workers’ compensation. Statute of Limitations: The time frame set for filing a claim. Also see Date of Injury and Claim Form. Even if the Statute of Limitations has run, the Commission does not discourage an injured worker from filing a claim. Statutory Employer: A person or business owner that hires or contracts work to another person or subcontractor to perform work that is either: 1) part of their own trade, business or occupation; or 2) to fulfill a contract or any part of a contract. Subpoena Duces Tecum: A document that requires records be sent to the requester (certain rules apply regarding the issuance of this document). Subpoena for Witness: A document that requires a witness to appear at a hearing (certain rules apply regarding the issuance of this document). Subsequent Report of Injury (SROI): A subsequent report sent to the Commission to report the initiation and suspension of indemnity payments and the total medical payments made to date. Supreme Court of Virginia: The highest court in the Commonwealth of Virginia. It hears cases that are initially appealed to the Court of Appeals of Virginia. 52  VIRGINIA SPECIFIC TERMS (CONTINUED) Temporary Partial Disability Benefits (TPD): If the injured worker cannot return to regular work and is given a light duty job at a lower wage, benefits are 2/3 of the difference between the pre-injury wage and the current pay, up to the maximum weekly limit. Cost of living supplements are not paid on temporary partial benefits. Temporary Total Disability (TTD): While temporarily unable to perform any work, an injured worker is entitled to 2/3 of their gross average weekly wage up to a set maximum weekly limit. There must be seven days of disability before benefits are payable. However, if disabled for more than three weeks (21 days), the injured worker receives payment for the first seven days. If an injured worker is released to return to work with restrictions but the employer has no work within those restrictions, an injured worker may receive temporary total disability benefits but must market their residual capacity to find work within those restrictions. Benefits cannot exceed 500 weeks unless the person is permanently and totally disabled. Also see Light Duty Restrictions. Termination of Wage Loss Award (Form #CSD-133): This form is to be completed by the Claim Administrator when the injured worker returns to work at the pre-injury wage or is able to return to pre-injury work. Transportation Expenses: See Lifetime Medical Benefits. Treating Doctor: See Treating Physician. Treating Physician: The physician selected by the injured worker from the panel of physicians provided by the employer/insurance carrier. Also see Panel of Physicians. Uninsured Employer’s Fund (UEF): A fund administered, maintained, and disbursed by the Commission, through which benefits can be paid if the employer is illegally uninsured for workers' compensation. 53  VIRGINIA SPECIFIC TERMS (CONTINUED) Venue: The location of the hearing is called the venue. On most occasions, a case is set for hearing in the city or county where the accident occurred or in an adjacent county. However, the Commission has the discretion to set a case in a venue different from the location where the accident occurred. Virginia Victims Fund (VVF): The Virginia Victims Fund (VVF), officially the Criminal Injuries Compensation Fund, is a state program created to help victims of violent crime with out-of-pocket expenses. Expenses include medical bills, prescriptions, funeral expenses, and many others. The program is administered by the Virginia Workers' Compensation Commission. For more information, contact [email protected] or 800-552-4007. Virginia Workers’ Compensation Act (Code Section 65.2): The Virginia Workers' Compensation Act ("the Act") was enacted on March 21, 1918, and became effective on January 1, 1919. The Act was intended to provide a comprehensive benefit structure for injured workers. It provides wage loss benefits as well as reimbursement for medical expenses related to the compensable injury. The Virginia Workers' Compensation Commission administers the provisions of the Act generally, and acts as an adjudicator where a dispute arises between the parties as to workers' rights or employers' obligations. Virginia Workers’ Compensation Commission: The agency charged with administering the Virginia's workers' compensation program, which applies to most employers doing business in Virginia and most employees working in Virginia. The Commission is a court system and is not an advocate for injured workers. The Commission does not provide the following: legal advice/legal guidance, legal representation, distribution of money, or schedule medical appointments, except in cases of IMEs. The Commission is headed by three Commissioners and an Executive Director. Commission also means the Virginia Workers’ Compensation Commission as well as its former designation as the Virginia Industrial Commission. 54  VIRGINIA SPECIFIC TERMS (CONTINUED) Vocational Rehabilitation: A benefit covered under the Virginia Workers’ Compensation Act. Vocational rehabilitation services may include vocational evaluation, counseling, job coaching, job development, job placement, on-the-job training, education, and retraining. Wage Replacement: See Temporary Total Disability (TTD) benefits and Temporary Partial Disability (TPD) benefits. WebFile: The Virginia Workers' Compensation Commission's online portal to electronic records. WebFile has been set up so that, based on your role, one can manage records and take care of key transactions online. For more information regarding WebFile, please visit the website https://webfile.workcomp.virginia.gov or contact the Customer Contact Center at 877-664-2566. Work Restrictions: The treating physician’s description of the work an injured worker can and cannot do. 55 VIRGINIA SPECIFIC TERMS (CONTINUED) Workers’ Compensation: A mandatory insurance requirement for most employers. It provides statutory benefits to covered workers who are injured in their employment. Virginia law requires every employer who regularly employs more than two employees part-time or full-time to carry workers’ compensation coverage. If a business hires subcontractor to perform the same trade, business or occupation, or to fulfill a contract of the business, the subcontractor’s employees are included in determining the total number of employees. Workers’ compensation insurance is also required for every operator of underground coal mines. Employers with fewer than three employees or who meet another exception under the Act may voluntarily take out a workers’ compensation policy or qualify as a self-insurer. In Virginia there are four means of insuring for workers’ compensation: (1) insurance carrier licensed for workers’ compensation in Virginia; (2) employer authorized to self-insure by the Commission (must meet distinct criteria); (3) be a member of a licensed group self-insurance association; and (4) enter an agreement with a professional employer organization (PEO) registered in Virginia. Commercial coverage is available from an insurance agent or insurance carrier. The Commission cannot recommend one agent over another. The two Virginia insurance organizations that maintain membership of most insurance agents in Virginia are listed below: 1. The Independent Insurance Agents of Virginia, 804-747-9300 2. The Professional Insurance Agents Association of Virginia, 804-264-2582 Work Restrictions: The treating physician’s description of the work an injured worker can and cannot do. 56 Addendum #2- Link to VA’s WC Administrators Worker’s Comp Commission https://workcomp.virginia.gov/ 57 Addendum #3- Links to your state’s Worker’s Comp Administrator’s annual report https://workcomp.virginia.gov/sites/default/files/annual-reports/VWC-Annual-Report-2021.pdf BONUS: https://workcomp.virginia.gov/sites/default/files/Injuries-by-Locality-2021.pdf 58 The End 59