The following is from our blog article A Worker’s Guide to Workers’ Comp Part I: I Was Injured at Work!

Taking Precautions

It goes without saying that paying attention to yourself and your surroundings can reduce the likelihood of workplace injuries. That being said, even when practicing all the precautions and preparations in the world, accidents still happen.

Notify Your Employer

Notify your employer that there has been an injury (or illness) in the workplace as soon as soon as possible. It is important to keep the employer in the loop as much as possible about what is happening. Failing to notify an employer about a workplace injury or illness at the time it happens may result in negative outcomes further down the line.

Take Care of Your Injury or Illness Now

As soon as you inform your employer, handle the injury as if it happened at home or anywhere else. Do you need to go to the emergency room? Do you need an ambulance? Alternatively, if you’ve developed a sickness or bodily condition due to workplace conditions over time, do you need to schedule a doctor’s appointment?

Filing a Claim

You must file a workers’ compensation claim in order to receive benefits. If you are able to remain on the job site with your employer, you should fill out a claim form immediately. On the claim form is a section for the employee, and a section for the employer. Fill out the employee section of the form and make a copy or take a picture. Your employer must send the form to the insurance adjuster within one working day of filling out the form. If you have to leave the job site before filling out a claim form for emergency purposes, your employer is required to provide you a claim form within 1 day of the injury. If you haven’t received this form for any reason, you can download and print the claim form here (for California only). After filling out your section of the form, remember to make a copy or take a picture of the form, and send off the original copy to your employer.

Does this Really Count as a Work Injury?

If uncertain about whether the situation requires workers’ compensation, you need to discuss this with your human resource (HR) contact and they can consult the workers’ compensation insurance carrier for next steps. RateFast’s own Dr. John Alchemy has given the run-down as to when injuries are recordable, or when they simply require first aid. Be aware that if you file a claim for an injury that did not happen, or if you are exaggerating to get out of work and receive benefits, this is workers’ compensation fraud, which can result in a felony offense, jail time, and thousands of dollars in penalties.

The following is from our blog article: A Worker’s Guide to Workers’ Comp Part II: Making the Most of Your Injury

Once Your Claim is Accepted, or if it isn’t…

It is the business of the insurance adjuster to accept your work comp claim as legitimate. Once they do, it is time for you to find a PTP (Primary Treating Physician), who will be the doctor who examines you solely for your claim. It is important to note that your PTP is not your primary care physician, so they cannot give you medical care for anything outside of your claim. Finding a PTP for yourself varies from business to business. Generally, either the insurance adjuster will contact you, or your employer will offer you a clinic or list of PTPs within their network. Once you have been presented with a clinic, or choice of clinics for your PTP, you must schedule an appointment with them in order to move your claim forward. There is no specific amount of time between being given PTPs to choose from, and having your first appointment, but the longer that you wait, the more likely it is that the insurance adjuster will cancel benefits for your claim.

Following Up, and What to Expect

Once you have been assigned, or have chosen, a designated PTP for your claim, you must have follow up appointments every 45 days to continue receiving benefits. During your appointments, the PTP will make specific examinations on the affected bodypart(s) and measure them based off of the criteria in the state’s designated workers’ comp rule set. For California, the rule set is the AMA Guides 5th Edition. The rule set has parameters for the specific body part, and gives the doctor a framework from which to measure your injury. If you injured your shoulder for example, the PTP will examine the range of motion, level of pain when moving it, etc. Other things that the doctor will ask you about when figuring out your level of impairment from the injury are your ADLs (Activities of Daily Living). You will be asked from a set of day-to-day activities, which ones have been affected by your injury, and which are not. Depending on your injury, you might have to get diagnostic tests performed, as well as examinations from other specialists. It is the responsibility of you and your PTP both to give as much information as possible about the progress of your injury to make sure that you get your benefits. The insurance adjuster can refuse the treatment your doctor requested from them if they feel that your measurements were wrong or incomplete. Make sure that you tell them everything that you have been experiencing about your injury.

Do I Get to Go Back to Work?

During the course of your claim, the PTP will decide based off of the measurements described above, if you are able to return to work, and how much you are able to do there. Your injury causes what are known as ‘functional limitations’. It is the responsibility of your workplace to find a job for you that you are able to do with your injury. Sometimes you are able to do the same job, but you are not allowed to lift as much weight as before. If you are not able to go back to work at all, you may be eligible for retraining.

Roadblocks

Workers’ comp is a complicated and deeply bureaucratic system due to regulations. The people keeping the balance are you, your PTP, your employer, and your employer’s insurance adjuster. All of these people are stakeholders in the claim. All of the stakeholders have the same goal, providing benefit and treatment as permitted by guidelines and regulations. Each stakeholder can have an issue with the claim somewhere in the process. You, the injured worker, might have an issue with the adjuster if they are refusing treatment for your injury. You might also take issue with your PTP because you feel that they are not taking your measurements correctly. The adjuster might also take issue with your PTP for the same reason. When this happens, one of the stakeholders may call in a workers’ comp attorney, or a QME (Qualified Medical Examiner), to try to correct the issue they have with the claim. These people brought into the claim are now considered stakeholders as well, and the dispute results in making the claim more expensive, and more drawn out. Click here to find out more about QMEs, and if you should get one. Click here to find out about work comp attorneys, and whether you should get one.

The following is from our blog article: RateFast Definitions: Stakeholders in Workers' Comp

A stakeholder is any party involved in a workers’ compensation claim. Any stakeholder in the claim has the ability to affect the claim in some way, though the extent varies from party to party.

The usuals

In every work comp claim, the stakeholders are:

• The injured worker – The subject of the claim at hand. 
• The PTP (primary treating physician) – The physician whom the worker sees that examines and rates the worker’s injuries.
• The employer – The company or organization in charge of the facilities where the injury arose out of or in the course of.
• The employer’s insurance carrier – The company responsible for paying the injured worker and the PTP. Having this responsibility entitles the insurance company to scrutinize and take action on the PTP’s findings.

When you need backup

Some work comp claims are disputed, and extra stakeholders may join to represent parties in the claim. Additional stakeholders may be:

• A QME (qualified medical examiner) – a physician usually representing the employer’s insurance, who will examine an injured worker when the employer’s insurance disputes a claim. A second opinion from a third party, if you will.
• An attorney – because work comp claims involve money, things get complicated. An attorney can be hired by either the worker or the employer. The attorney has the right to order a deposition from the physician in disputed claims.
  • The injured worker may seek an attorney when the insurance refuses or delays the payment for an injury.
  • The employer’s insurance may seek an attorney when they are suspicious of the findings of the PTP, or the testimony of the injured worker.

As work comp claims snowball more stakeholders, they grow in complexity and expense.

Frequently Asked Questions About Work Injuries answered by the California Division of Workers’ Compensation:

What is an Permanent and Stationary/Impairment/PR-4 exam?:

An impairment exam is a special visit with the doctor to tell your whole story of your injury to the insurance carrier. Sometimes this exam report is called an “Permanent and Stationary Report “(P & S), an “Impairment Report” or a “PR-4” report.

The physician will conduct a Permanent and Stationary Exam when they have determined that your injury has healed to its maximum extent. The doctor takes the notes from the examination and writes a report that tells the insurance carrier the extent that your injury affects you.

The visit requires answering some questions about your work injury, and the doctor performing a physical exam and taking special measurements. This exam is important to distribute the future benefits of your claim.

Why isn’t my regular work injury doctor doing this exam?:

Your doctor has referred you to an “impairment rating specialist” doctor because this report requires an expert to write your report correctly. Each year we write approximately 1,500 of these reports for injured workers and their insurance carriers. This report must be written using a special book called the “American Medical Association Guides to the Evaluation of Permanent Impairment 5th Edition”.

What if I still have pain? I am afraid that I cannot return to my job.:

The impairment report will tell your employer and insurance carrier about your ability to return to work. This opinion will include what you can and cannot do at work. The report will take into account your pain/symptoms, the physical exam findings, and any tests or studies that have been performed during your care. If the doctor determines you have ongoing work restrictions as a result of your injury, these restrictions will now be called “Permanent Functional Restrictions”.

What if I am unhappy with my impairment report findings or disagree with the doctor? :

Workers’ Compensation injuries can be complicated. Your pain and symptoms must be considered along with the findings of your physical exam and any tests performed. If a finding on the exam is unclear or does not make sense to you, consider first talking to your evaluating doctor at the exam. If your questions still remain, it is recommended you then speak with your insurance adjuster, or designated employer representative. Finally, you may consider seeking a second opinion in the “Panel Qualified Medical Examiner” system, sometimes called a “QME”.

What is a QME?:

The letters “QME” stand for “Qualified Medical Examiner”. To become a QME, the doctor, or health professional, must pass a state written examination to demonstrate competency in the basic rules and regulations of California’s Workers’ Compensation system. Upon completion of this test, the doctor or health professional, is now certified to perform independent evaluations to help injured workers and insurance carries answer questions that may be delaying the claim. Injured workers or their insurance carriers may request a QME exam for purposes of a second opinion. For more information on the QME system you may contact the California Division of Workers’ Compensation (DWC)