Chapter 2: Organization of the Workers' Compensation System PDF

Chapter 2 Organization of the Workers’ Compensation System within State Government 4  Chapter 2 Key concepts: x Division of Workers’ Compensation (DWC) x Workers’ Compensation Appeals Board (WCAB) x Audit Un...

Chapter 2 Organization of the Workers’ Compensation System within State Government 4  Chapter 2 Key concepts: x Division of Workers’ Compensation (DWC) x Workers’ Compensation Appeals Board (WCAB) x Audit Unit x Disability Evaluation Unit (DEU) x Information and Assistance (I&A) Unit x Legal Unit x Medical Unit x Research Unit x Workers’ Compensation Information System x Uninsured Employers Benefits Trust Fund (UEBTF) x Subsequent Injuries Benefits Trust Fund (SIBTF) California’s Division of Workers’ Compensation (DWC) The Division of Workers’ Compensation (DWC) monitors the administration of workers’ compensa- tion claims and provides administrative and judicial services to assist in resolving dis- putes that arise in connection with claims for workers’ compensation benefits. DWC’s mission is to minimize the adverse impact of work-related injuries on California em- ployees and employers. At the DWC’s 24 district offices and satellites located around the state, also called Workers’ Compensation Appeals Boards (WCABs) or “boards,” employ- ers, injured workers, and others receive judicial services to assist in the prompt and fair resolution of disputes that sometimes arise from workers’ compensation claims. Local district offices are a major part of the workers’ compensation court system, where ad- ministrative law judges make decisions about cases. Appeal from this level is available by Petition for Reconsideration to a statewide panel of commissioners. Decisions issued by the WCAB are appealable to the state trial courts, and then to the California Courts of Appeal and the California Supreme Court. The administrative director (AD) is vested with authority to do all things necessary or convenient in the exercise of any power or jurisdiction conferred upon the AD under the Labor Code. The AD oversees the diverse programs of the DWC and oversees the implementation of workers’ compensation re- forms. The Workers’ Compensation Appeals Board (WCAB) Distinct from the “boards” mentioned above, the WCAB is a judicial body consisting of seven commissioners, appointed by the governor, and confirmed by the Senate. Major functions of the WCAB include review of Petitions for Reconsideration of decisions by Workers’ Compensation Administrative Law Judges and regulation of the adjudication process by adopting rules of practice and procedure. The Audit and Enforcement Unit The Audit and Enforcement Unit conducts audits of insurance companies, self-insured employers, and third-party administrators to ensure that they have met their obligations under the Labor Code 5  Chapter 2 and DWC’s regulations. By assessing penalties and ordering that carriers to pay compensation that is owed to injured workers, this unit ensures that proper benefits are delivered accurately and in a timely manner. Disability Evaluation Unit (DEU) The DEU determines permanent disability ratings by evaluating medical descriptions of physical and mental impairment. The determinations are used by Workers’ Compensation Administrative Law Judges, injured workers, and insurance claims administrators to determine permanent disabil- ity benefits. The DEU prepares three types of ratings: x Formal, done at the request of a workers’ compensation judge x Consultative, done on litigated cases at the request of an attorney or DWC information and assistance officer x Summary, done on non-litigated cases at the request of a claims administrator or injured worker. Information & Assistance (I&A) Unit The DWC I&A Unit provides information and assistance to employees, employers, labor unions, in- surance carriers, physicians, attorneys, and other interested parties concerning rights, benefits, and obligations under California’s workers’ compensation laws. The unit plays a major role in reducing litigation before the WCAB and is often the first DWC contact for injured workers. The unit’s I&A officers assist in the resolution of misunderstandings, disputes, and complaints arising out of claims for compensation. The I&A officers also conduct seminars for injured workers on a monthly basis at each of DWC’s 24 local district offices. At the seminars, employees get infor- mation on their right to medical treatment, disability payments, returning to work after an injury, and resolving a disagreement over a claim. Additional information is available that may be helpful: x Workers’ compensation benefits: Overview of benefits, including currents rates, available for injured workers x Fact sheets and guides for injured workers: Answers to frequently asked questions and “how to” guides for forms x Glossary of workers’ compensation terms for injured workers x Workers’ compensation reference materials: Other sources of information on the workers’ comp system x Medical mileage expense form in both English and Spanish x Simplified flowchart for the claims process Medical Unit Under the direction of the executive medical director, the Medical Unit performs a variety of ser- vices related to the delivery of medical benefits in the workers’ compensation system. It establishes policy and guidelines for the treatment and evaluation of injured workers. The unit examines and appoints physicians to be Qualified Medical Evaluators (QMEs), who in turn examine injured work- 6  Chapter 2 ers to help resolve medical disputes. The unit also investigates complaints filed against QMEs con- cerning violations of the Labor Code and regulations as well as other statutes for misconduct com- mitted in the QME process (Chapter 13). The Medical Unit also approves or certifies and oversees medical provider networks (MPNs) and health care organizations (HCOs) that provide care to in- jured workers (Chapter 6). The unit reviews utilization review (UR) plans and handles UR com- plaints and investigations jointly with the Audit Unit (Chapter 13) and reviews independent medical review (IMR) and independent bill review (IBR) requests to determine eligibility (Chapters 9 & 12). The Medical Unit also assists the AD with other issues affecting providers in the workers’ compensation system, such as setting medical fee schedules (Chapter 12). Additional details are available on the following Medical Unit Programs: x Discipline Unit x e-billing x Health care organizations (HCO) x Independent bill review (IBR) x Independent medical review (IMR) x Medical provider network (MPN) x Medical treatment utilization schedule (MTUS) x Official medical fee schedule (OMFS) x Qualified Medical Evaluator (QME) process x Standardized paper billing x Utilization review (UR) Workers’ Compensation Information System (WCIS) WCIS uses electronic recordkeeping data interchange to collect comprehensive information from claims administrators to help DIR oversee the state’s workers’ compensation system. This infor- mation helps facilitate evaluation of the system and measure adequacy of benefits for injured workers and their dependents, and provides statistical data for research. As of September 22, 2006, all elements of a workers’ compensation claim including employers’ first reports of injury, benefit notices, and reporting of medical billing are required to be electronic. Uninsured Employers Benefits Trust Fund (UEBTF) and Subsequent Injuries Benefits Trust Fund (SIBTF) Claims are paid from the UEBTF when illegally uninsured employers fail to pay workers’ compensa- tion benefits awarded to their injured employees by the WCAB. Certain steps must be taken before and after the issuance of an award in order to receive benefits from the UEBTF. How to File a Claim with the Uninsured Employers Benefits Trust Fund is a guide offering detailed steps to pursue a claim for benefits from the UEBTF. The SIBTF is a source of additional compensation to injured workers who already had a disability or impairment at the time of injury. For benefits to be paid from the SIBTF, the combined effect of the injury and the previous disability or impairment must result in a permanent disability of at least 70%. The fund enables employers to hire disabled workers without fear of being held liable for the effects of previous disabilities or impairments. SIBTF benefit checks are issued to injured workers by the SIBTF Claims Unit after benefits are awarded by the WCAB. The Application for Subsequent Injuries and Benefits must be completed to obtain SIBTF benefits. 7