Worker’s compensation 05.09.12
-
Upload
alice-m-adams-rn-legal-nurse -
Category
Health & Medicine
-
view
231 -
download
1
description
Transcript of Worker’s compensation 05.09.12
![Page 1: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/1.jpg)
Worker’s CompensationThe Rules of the Game
Alice M. Adams, RNMay 14, 2012
[email protected] 404-771-5155
1
![Page 2: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/2.jpg)
Define the parameters of an accepted work-related injury and the employer’s possible defense to that injury.
Identify the nursing role in attending IME appointments with patients and assisting attorneys with controverted claims
Careers in Legal Nurse Consultingwww.lncConference.com
Saturday July 21, 2012
Objectives
2
![Page 3: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/3.jpg)
Commonalities among states
HIPAA
Medical Only vs Lost-Time
What is Workers’ Compensation?
3
![Page 4: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/4.jpg)
Texas 4
![Page 5: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/5.jpg)
CaliforniaQME IME DME SSSOP IMR
5
![Page 6: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/6.jpg)
Georgia6
![Page 7: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/7.jpg)
General Concepts
• What is workers’ compensation• When does coverage begin• What is considered an injury• Report within 30 days, file within one year• Horseplay, haste and inattention• Exclusive remedy• Lawsuit/subrogation lien• Lawyer fees• Loss of benefits 7
![Page 8: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/8.jpg)
Employee’s Responsibilities
1. Report within 30 days2. Accept treatment & rehab3. RTW, reduced earnings, compensation4. Job attempt5. Statute of limitations6. Drug test refusal7. False and misleading statements
http://www.files.georgia.gov/SBWC/Files/employee_handbook.pdf
8
![Page 9: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/9.jpg)
What might rouse the suspicions of an employer?
9
![Page 10: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/10.jpg)
What is an IME?
An IME is an opportunity to have a different doctor physically examine an injured worker and review their medical records and diagnostic tests for the purpose of providing a second opinion. The IME doctor should make a diligent effort to address some of the issues the patient is having and try to figure out what is or is not going right medically speaking. He or she may also address the injured worker's current work restrictions, treatment options, the necessity of a recommended surgery, and when applicable, the injured worker's permanent partial disability rating if one has been issued.
http://www.georgiaworkerscompensationadvocate.com
QME IME DME AME PME SSSOP IMR
10
![Page 11: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/11.jpg)
1. When I find a client's diagnostic tests are consistent with a serious injury… but the treating physician is skeptical of the employee's complaints.
2. When my client is doubtful of the diagnosis, treatment options, or work restrictions, I will recommend an IME for the sole purpose of addressing my client's concerns.
3. When my client has an unusual condition such as Complex Regional Pain Syndrome, and an expert is required for a diagnosis or treatment plan.
When does Bryan S. Hawkins, Pltf Atty, request an IME?
http://www.georgiaworkerscompensationadvocate.com11
![Page 12: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/12.jpg)
What Can You Do?
12
![Page 13: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/13.jpg)
Why would you attend an IME?Ask the attorney what he wants
Meet and prepare the patient
Review the records
Provide a summary if requested
A pre-approved silent observer
Chart what is said and done, wait times, staff and physician attitude
When the patient may notunderstand or is frightened
When the care is complex
When the physician is unknown
When the physician is known
13
![Page 14: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/14.jpg)
Confidential Work Product of the LNC who is hired by the plaintiff attorney
14
![Page 15: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/15.jpg)
Duties of the Case Manager
• Medical Management• Vocational Evaluation• Identifying medical or return to work issues• Job descriptions• Medical Cost Analysis• Communication with medical providers to clarify
treatment plans
Zan Lanford, RN,CCM, Wright Rehabilitation Services
15
![Page 16: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/16.jpg)
Seeing the big picture by looking at the totality of care
When patient advocacy means less care
The case of Mr. Cilantro
Loss of objectivity can lead to iatrogenic complications
Sometimes, NO is in the patient’s best interests
Remember the campfire game of whispering into each others’ ears?
16
![Page 17: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/17.jpg)
Psychological Complications
When is care allowedWho makes the call
What is usual and customaryWhat about pre-existing
from Mr. H. Dill Battle, III of Spillman Thomas & Battle, PLLC
http://www.workerscompensation.com/compnewsnetwork/workers-comp-blogwire/14043-wv-sca-secondary-condition-psychiatric.html
http://www.spilmanlaw.com
17
![Page 18: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/18.jpg)
Patients vs. Injuries
Dr. David B. Adamswww.psychological.com
“it is often more important to know what type of patient has the injury
…rather than to know what type of injury the patient has…”
18
![Page 19: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/19.jpg)
My 10 Critical Diagnostic Data – All Pain Patients
•The Patient’s Developmental History•The Patient’s Educational History•The Patient’s Medical History (including addiction)•The Patient’s Work History•The Patient’s Recounting of the Accident•The Patient’s Understanding of the Physical Damages•The Patient’s Assessment of Medical Care•The Patient’s Expectations and Future Goals
19
![Page 20: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/20.jpg)
• Forgotten appointments
• Last minute excuses & broken promises
• Over-sedation
• Illiteracy
Poor prognosis
Dr. David B. Adamswww.psychological.com 20
![Page 21: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/21.jpg)
Identifying Depression
1. Has patient lost or gained significant weight?2. Is there a specific sleep problem?3. Is the patient irritable?4. Is the patient forgetful, have difficulty concentrating
and/or have trouble making decisions?5. Does the patient feel guilty and/or worthless?6. Is the patient readily tearful?7. Has the patient ceased to enjoy hobbies or interests?8. Is there a decrease in libido?9. Is there psychomotor agitation or retardation?10. Does the patient express thoughts about death?
Dr. David B. AdamsAtlanta Medical Psychology 21
![Page 22: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/22.jpg)
What is a WC-3 filing?
22
![Page 23: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/23.jpg)
Controverted claims and Potential Employer Defenses
Arising out of and in the course of employment
Rycroft analysis
Deviation from employment
Intoxication /Fighting/Horseplay/Suicide
23
![Page 24: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/24.jpg)
What Can You Do?
24
![Page 25: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/25.jpg)
The Controverted Claim
25
![Page 26: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/26.jpg)
1. Is the condition an actual “injury”?2. Did it occur in the course of employment?3. Did the injury arise out of employment?
26
![Page 27: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/27.jpg)
Angina (caused by disease, worsened by exertion, involves no death of tissue) is more of a recurrent symptom vs Myocardial Infarction (an acute MI involves actual death of tissue and actual damage
TIA (ischemic, resolving within 24 hours)vsCVA (80% ischemic, 20% hemorrhagic)
Disease vs Injury -What’s the Difference?
27
![Page 28: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/28.jpg)
Medical Evidence to support “in the course of”:
-serum enzyme changes (time-specific)-EKG-nonspecific indices of polymorphonuclear leukocytosis-cardiac imaging
28
![Page 29: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/29.jpg)
Arising Out Of……….But For
“There must be some causal connection between the conditions under which the employee worked and the injury which he received.”
And
“The cause of the injury must be incidental to, rather than independent of, the employer-employee relationship.”
Time matters – the shorter the interval, the stronger the case for causation
29
![Page 30: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/30.jpg)
How hard was the patient working?
It may not matter. Georgia is not among those states which require that the job-related physical exertion be an unusual one. The plaintiff could have even been doing lighter than usual work that day.
In the Georgia Laws, 1963: P. 141: the heart attack can be “…attributable to the performance of the usual work of employment”
But, awards have been upheld when undue emotional stress precipitated a cerebral hemorrhage.
Another was upheld when the cerebral hemorrhage was due to his working when it was unusually hot (rather than to his drinking iced tea).
What matters: Drawing the line between a noncompensable heart disease that manifests itself at work, and a compensable heart injury to which the job exertion was a contributing factor”(Guye v. Home Indemnity Company, 141 Ga. 213, 244, S.E.2d 864(1978)
30
![Page 31: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/31.jpg)
So…What Can You Do?
31
![Page 32: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/32.jpg)
32
![Page 33: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/33.jpg)
www.psychological.comDiagnoses, Forums, Workers’ Comp. Blog & Online Referral
33
![Page 34: Worker’s compensation 05.09.12](https://reader035.fdocuments.us/reader035/viewer/2022070303/549757b5b47959102b8b47f1/html5/thumbnails/34.jpg)
http://blog.reduceyourworkerscomp.com/2010/04/know-the-difference-between-lost-time-and-medical-only-claims-shades-of-gray/#axzz1uO8kesDS
http://www.georgiaworkerscompensationlaw.net/denial_of_claim_based_on_inacc.html
http://www.dir.ca.gov/dwc/
http://sbwc.georgia.gov/portal/site/SBWC/
http://www.tdi.texas.gov/wc/index.html
www.psychological.com
http://www.nursingworld.org/Research-Toolkit
http://www.guidelines.gov/
34