HCR 202 University of Phoenix Federal and State Compensation Plans Discussion

SOLUTION AT Academic Writers Bay

12 WORKERS’ COMPENSATION Page 377 AND DISABILITY/AUTOMOTIVE INSURANCE Learning Outcomes After studying this chapter, you should be able to: 12.1 Explain the four federal workers’ compensation plans. 12.2 Describe the two types of state workers’ compensation benefits. 12.3 Classify work-related injuries. 12.4 List three responsibilities of the physician of record in a workers’ compensation case. 12.5 Differentiate between Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). KEY TERMS Admission of Liability automobile insurance policy disability compensation program Federal Employees’ Compensation Act (FECA) Federal Insurance Contribution Act (FICA) final report first report of injury 1694489 – McGraw-Hill Higher Education (US) © independent medical examination (IME) lien Notice of Contest occupational disease or illness Occupational Safety and Health Administration (OSHA) Office of Workers’ Compensation Programs (OWCP) personal injury protection (PIP) physician of record progress report Social Security Disability Insurance (SSDI) subrogation Supplemental Security Income (SSI) vocational rehabilitation Workers’ compensation was developed to benefit both the employer and the Page 378 employee. It provides employees who are injured on the job with compensation for their injuries, and it protects employers from liability for employees’ injuries. Before workers’ compensation was established in the United States in the early 1900s, injured workers’ only recourse was to pursue legal action against the employer. To be successful, the employee had to prove that the employer was negligent. Cases were often difficult to prove and took years to settle. By 1947, all states required employers to purchase workers’ compensation insurance. Congress created the Occupational Safety and Health Administration (OSHA) in 1970 to protect workers from health and safety risks on the job. OSHA sets standards to guard against known dangers in the workplace, such as toxic fumes, faulty machinery, and excess noise. Businesses must meet health and safety standards set by OSHA. If they do not, they are subject to significant fines. Almost all employers are governed by OSHA legislation; the few exceptions include independent contractors, churches, domestic workers in private home settings, and federal employees (whose health and safety are the responsibility of federal agency programs). An employee who believes that the work environment is unhealthy or unsafe may file a complaint directly with OSHA. The employer is prohibited from treating the employee adversely for filing a complaint with OSHA. 12.1 Federal Workers’ Compensation Plans Work-related illnesses or injuries suffered by civilian employees of federal agencies, including occupational diseases they acquire, are covered under various programs administered by the Office of Workers’ Compensation Programs (OWCP). OWCP is part of the U.S. Department of Labor. The programs are: The Federal Employees’ Compensation Program, which provides workers’ compensation benefits to individuals employed by the federal government under the Federal Employees’ Compensation Act (FECA) The Federal Black Lung Program, under the administration of the Division of Coal Mine Workers’ Compensation, which provides benefits to individuals working in coal mines under the Black Lung Benefits Act The Energy Employees Occupational Illness Compensation Program, which went into effect on July 31, 2001, and provides benefits under the Energy Employees Occupational Illness Compensation Program Act for workers who have developed 1694489 – McGraw-Hill Higher Education (US) © cancer and other serious diseases because of exposure to radiation, beryllium, or silica at atomic weapons facilities or at certain federally owned facilities in which radioactive materials were used The Longshore and Harbor Workers’ Compensation Program, which provides coverage for individuals employed in the maritime field under the Longshore and Harbor Workers’ Compensation Act and for certain other classes of workers covered by extensions of the act Each program provides medical treatment, cash benefits for lost wages, vocational rehabilitation, and other benefits to workers of the employee group or industry it represents who have sustained workplace injuries or acquired occupational diseases. FECA Program Information www.dol.gov/owcp/regs/compliance/ca_feca.htm THINKING IT THROUGH 12.1 Page 379 1. Workers’ compensation coverage provides important medical insurance benefits to people who experience work-related injuries or illnesses. Unfortunately, many instances of abuse of workers’ compensation have been uncovered. In a significant number of these situations, court cases have found workers’ claims for temporary or permanent disability to be untruthful. Are medical office staff members responsible for questioning or reporting information they suspect to be fraudulent? 12.2 State Workers’ Compensation Plans Each state administers its own workers’ compensation program and has its own statutes that govern workers’ compensation, so coverage varies from state to state. However, all states provide two types of workers’ compensation benefits. One pays the employee’s medical expenses that result from the work-related injury, and the other compensates the employee for lost wages while he or she is unable to return to work. Workers’ compensation pays for all reasonable and necessary medical expenses resulting from the work-related injury. COMPLIANCE GUIDELINE Patient Rights A federal worker injured on the job may select a physician from among those authorized by the OWCP. Payment is made directly to the provider based on the Medicare Fee Schedule. The patient may not be billed for excess charges beyond the allowed charge. Employers obtain workers’ compensation insurance from one of the following sources: (1) a state workers’ compensation fund, (2) a private plan, or (3) directly with a self-insured fund. Under a state fund, companies pay premiums into a central state insurance fund from which claims are paid. Many employers contract with private insurance carriers, which provide access to their networks of providers (primary care physicians, occupational 1694489 – McGraw-Hill Higher Education (US) © medical centers, urgent care centers, physical therapy providers, chiropractors, radiology centers, orthopedists, and orthopedic surgeons and facilities). When a firm self-insures, it sets money aside in a fund that is to be used to pay workers’ compensation claims. Most states require a company to obtain authorization before choosing to self-insure. Regardless of the source of workers’ compensation insurance, the money that funds workers’ compensation insurance is fully paid by the employer; no money is withdrawn from an employee’s pay. Links to States’ Workers Compensation Agencies www.workerscompensation.com Employers or their insurance carriers must file proof of workers’ compensation insurance with the state Workers’ Compensation Board. In some states, this proof may be filed electronically through a Web-based data-entry application. In addition, the employer must post a Notice of Workers’ Compensation Coverage in a place accessible to all employees. This notice must list the name, address, and telephone number of the administrator of the company’s workers’ compensation program. BILLING TIP Workers’ Compensation Fees Some states have mandated the use of relative value scale (RVS) (see the chapter about visit charges and compliant billing) unit values as the schedule of fees for workers’ compensation services. These states have often also set a conversion factor. Many, however, do not use RVS or the current procedural terminology (CPT) codes for their fee schedules. The office may have to crosswalk from the CPT code to the workers’ compensation fee schedule. Eligibility Most states require public and private companies to provide workers’ compensation coverage to all full-time and part-time employees, including minors if an organization employs more than three people. Companies that are required to carry workers’ compensation insurance but fail to do so are subject to legal penalties. The following categories of employee–employer relationships are generally not covered by state workers’ compensation insurance: Federal employees (because they are covered under a federal program) Railroad employees (because they are covered under a federal program) Self-employed individuals Real estate agents working on commission For-hire domestic, maintenance, or repair workers hired to perform a job for a homeowner on less than a full-time basis Drivers under a lease agreement with a carrier, such as some long-haul Page 380 truck drivers Inmates employed by a prison 1694489 – McGraw-Hill Higher Education (US) © Volunteers Independent contractors Clergy and members of religious orders Agricultural laborers Benefits Workers’ compensation insurance covers injuries, illnesses, and job-related deaths. Injuries are not limited to on-the-job occurrences. An injury may occur while performing an off-site service for the company, such as driving to office on its behalf. Accidents such as falls in the company parking lot are also covered under workers’ compensation rules. Occupational diseases or illnesses develop as a result of workplace conditions or activities. These include lung disorders caused by poor air quality, repetitive motion illnesses such as carpal tunnel syndrome, and occupational hearing loss, among others. Illnesses may develop rapidly or over the course of many years. Medical benefits are payable from the first day of the injury. Cash benefits vary from state to state and are generally not paid for the first seven days of disability. In most states, a worker must be disabled for more than seven calendar days before benefits are payable. However, if the disability extends beyond fourteen days, a worker may become retrospectively eligible for cash benefits for the first seven days. Different states have different methods of determining wage-loss benefits. Usually, the benefits are based on a percentage of the worker’s salary before the injury. For example, it is not uncommon for workers to be compensated at two-thirds of their average weekly wage, up to a weekly maximum. The weekly maximums differ among states, as do the formulas for determining workers’ average weekly wages. When an individual is fatally injured on the job, workers’ compensation pays death benefits to the employee’s survivors. Funeral expenses may also be paid. Covered Injuries and Illnesses States determine the types of injuries that are covered under workers’ compensation. Generally, an injury is covered if it meets all of the following criteria: It results in personal injury or death. It occurs by accident. It arises from employment. It occurs during the course of employment. An accident can be either an immediate event or the unexpected result of an occurrence over time. A worker who cuts a finger while using a box cutter is an example of an immediate accident. An employee who suffers a repetitive stress injury that developed over the course of several years is an example of an unexpected result over time. The following are examples of covered injuries: Back injuries due to heavy lifting or falls Repetitive stress injuries such as carpal tunnel syndrome Parking lot injuries such as falls Heat-related injuries such as heat stroke or heat exhaustion if the job requires a lot of work time in the hot sun 1694489 – McGraw-Hill Higher Education (US) © Hernias if they are related to a work injury Personal time injuries, such as injuries that occur in the cafeteria or restroom Page 381 Some generally covered injuries may be excluded from workers’ compensation, or benefits may be reduced if certain conditions were present at the time of the injury. Examples include the following: Employee intoxication by alcohol or illegal drugs led to the injury. The injury was intentionally self-inflicted. The employee violated the law. The employee failed to use safety equipment. The employee failed to obey safety procedures. The employee is also a recipient of Social Security disability benefits. The employee is also a recipient of unemployment insurance. The employee receives an employer-paid pension or disability benefit. THINKING IT THROUGH 12.2 1. Joe Marino works in the mailroom of a large telecommunications company. His job requires lifting packages in excess of eighty pounds. Over the course of his employment with the company, Joe has been out on temporary disability several times because of back pain. On his way home from work last Friday, Joe stopped by office to drop off some personal mail. As he was walking into office, he slipped on an icy patch on the sidewalk and injured his back. After an examination by his physician, Joe was ordered to stay out of work for a minimum of two weeks. Would this injury be covered under workers’ compensation insurance? Provide an argument to support your position. 12.3 Workers’ Compensation Terminology Classification of Injuries Work-related injuries are grouped into five categories. Injury Without Disability Workers’ compensation insurance pays all medical expenses for a worker who is injured on the job and requires treatment but is able to resume working within several days. Injury with Temporary Disability A worker is injured on the job, requires treatment, and is unable to return to work within several days. All medical expenses are paid by workers’ compensation insurance, and the employee receives compensation for lost wages. Compensation varies from state to state and is usually a percentage of the worker’s salary before injury. Before an injured employee can return to work, the physician must file a doctor’s final report indicating that he or she is fit to return to work and resume normal job activities. 1694489 – McGraw-Hill Higher Education (US) © Injury with Permanent Disability A worker is injured on the job, requires treatment, is unable to return to work, and is not expected to be able to return to his or her regular job in the future. Usually this employee has been on temporary disability for an extended period of time and is still unable to resume work. When that is the case, the physician of record files a report stating that the individual is permanently disabled. The state workers’ compensation office or Page 382 the insurance carrier may request an additional medical opinion before a final determination is made. An impartial physician is called in to provide an independent medical examination (IME). Once the IME report is submitted, a final determination of disability is made, and a settlement is reached. The length of coverage varies from state to state. When an employee is rated as having a permanent disability, workers’ compensation insurance pays all medical expenses, and the worker receives compensation for lost wages. The amount of compensation depends on a number of factors, including whether the disability is partial or total, the employee’s age, and the job performed before the injury. Partial disability is generally classified by percentage and varies by severity. For example, a worker who has lost the use of a hand would receive less compensation than a worker paralyzed from the waist down. Injury Requiring Vocational Rehabilitation A worker is injured on the job, requires treatment, and is unable to return to work without vocational rehabilitation. Workers’ compensation insurance pays all medical expenses as well as the costs of the vocational rehabilitation program. Vocational rehabilitation is the process of retraining an employee to return to the workforce, although not necessarily in the same position as before the injury. For example, an employee who injured his or her back working in a job that required heavy lifting may be trained for work that does not involve lifting. Injury Resulting in Death A worker dies as a result of an injury on the job. Death benefits are paid to survivors based on the worker’s earning capacity at the time of the injury. Pain and Disability Physicians who examine patients under workers’ compensation coverage use a set of standardized terms to describe the effects of work-related injuries and illnesses. Most states and insurance carriers use these widely accepted terms. Different terminology is used to describe levels of pain and the effects of injuries or illnesses. Pain Terminology Pain is classified as minimal, slight, moderate, or severe: Minimal pain is annoying but does not interfere with the individual’s ability to perform the job. Slight pain is tolerable, but the performance of some work assignments may be impaired. Moderate pain is tolerable, but the performance of some work assignments will show marked impairment. Severe pain requires avoiding activities that lead to pain. 1694489 – McGraw-Hill Higher Education (US) © Disability Terminology Disabilities due to spinal injuries, heart disease, pulmonary disease, or abdominal weakness are classified as follows: Limitation to light work: Individual may work in an upright or walking position as long as no more than minimal effort is required. Precluding heavy work: Individual has lost 50 percent or more of the ability to lift, push, pull, bend, stoop, and climb. Precluding heavy lifting, repeated bending, and stooping: Individual has lost 50 percent of the ability to perform these activities. Precluding heavy lifting: Individual has lost 50 percent of heavy lifting ability (categorization limited to lifting and does not include bending and stooping). Precluding very heavy work: Individual has lost 25 percent of the ability to Page 383 lift, push, pull, bend, stoop, and climb. Precluding very heavy lifting: Individual has lost 25 percent of the ability for very heavy lifting. Disabilities due to lower extremity injuries are described as follows: Limitation to sedentary work: Individual is able to work while in a sitting position with minimal physical effort required. Some walking and standing are possible. Limitation to semisedentary work: Individual is able to work in a job that allows 50 percent sitting and 50 percent standing or walking with minimal physical effort demanded. Workers’ Compensation and the HIPAA Privacy Rule Workers’ compensation cases are among the few situations in which a healthcare provider may disclose a patient’s protected health information (PHI) to an employer without the patient’s authorization. Workers’ compensation claim information is not subject to the same confidentiality rules as other medical records. Most states allow claims adjusters and employers unrestricted access to the workers’ compensation files. Likewise, at the federal level, the HIPAA Privacy Rule permits disclosures of PHI for workers’ compensation purposes without the patient’s authorization. Disclosure for any judicial or administrative proceeding in response to a court order, subpoena, or similar process is also allowed. Following the minimum necessary standard, covered entities can disclose information to the full extent authorized by state or other law. In addition, when a state workers’ compensation or other public official requests a PHI for such purposes, covered entities are permitted to reasonably rely on the official’s representations that the information requested is the minimum necessary for the intended purpose. Individuals do not have a right under the Privacy Rule to request that a physician restrict a disclosure of their PHI for workers’ compensation purposes when that disclosure is required by law or authorized by, and necessary to comply with, a workers’ compensation or similar law. However, for the physician to disclose information about a previous condition that is not directly related to the claim to an employer or insurer requires the individual’s written authorization. BILLING TIP 1694489 – McGraw-Hill Higher Education (US) © Workers’ Compensation Diagnosis Coding Diagnosis coding must include external cause codes (secondary, never primary) to report the cause of the accident, such as transport, falls, and fire/flames, and the place of the injury. THINKING IT THROUGH 12.3 1. Workers’ compensation cases provide one of the few situations in which a healthcare provider may disclose a patient’s protected health information to an employer without the patient’s authorization. Workers’ compensation claim information is not subject to the same confidentiality rules as other medical information. What is the reason for this exemption? 12.4 Claim Process HIPPA/HITECH TIP First Report of Injury Transaction Standard The first report of injury transaction will be one of the HIPAA electronic data interchange (EDI) standard transactions. The format and rules for the first report must be HIPAA-compliant after the uniform transaction standard is mandated under federal law. When an employee is injured on the job, the injury must be reported to the employer within a certain time period. Most states require notification in writing. Once notified, the employer must notify the state workers’ compensation office and the insurance carrier, also within a certain period of time. In some cases, the employee is given a medical service order to take to the physician who provides treatment. In most instances, the injured employee must be treated by a provider selected by the employer or insurance carrier. Some employers contract with a managed care organization for services. In these cases, the patient must be examined and treated by a Page 384 physician in the managed care plan’s network. If the employee refuses to comply with the request, benefits may not be granted. Responsibilities of the Physician of Record The physician who first treats the injured or ill employee is known as the physician of record. This physician is responsible for treating the patient’s condition and for determining the percentage of disability and the return-to-work date. A sample workers’ compensation physician’s report form is displayed in Figure 12.1. 1694489 – McGraw-Hill Higher Education (US) © FIGURE 12.1 Sample Workers’ Compensation First Report of Injury or Illness: Florida Source: “FIRST REPORT OF INJURY OR ILLNESS,” Florida Department of Financial Services, May 12, 2016. www.myfloridacfo.com The physician of record also files a progress report with the insurance carrier Page 385 every time there is a substantial change in the patient’s condition that affects 1694489 – McGraw-Hill Higher Education (US) © disability status or when required by state rules and regulations (see Figure 12.2 for a sample physician’s progress report). Providers submit their charges to the workers’ compensation insurance carrier, which makes payment directly. Charges are limited to an established fee schedule. Patients may not be billed for any medical expenses. In addition, the employer may not be billed for any amount that exceeds the established fee for the service provided. 1694489 – McGraw-Hill Higher Education (US) © FIGURE 12.2 Sample Physician’s Progress Report Form: Ohio Source: “Sample Physician’s Progress Report Form: Ohio,” Ohio DNR, February 1, 2011. www.ohiodnr.gov. 1694489 – McGraw-Hill Higher Education (US) © Responsibilities of the Employer and Insurance Carrier Page 386 The first report of injury form must be filed by either the employer or the physician (under state law) within a certain time period. The amount of time varies among states; the range is normally from twenty-four hours to ten days. The form contains information about the patient, the employer, and the injury or illness. Depending on the insurance carrier, the report may be filed electronically or mailed to the carrier. A first report of injury form is displayed in Figure 12.3. 1694489 – McGraw-Hill Higher Education (US) © FIGURE 12.3 Source: Employers First Report of Injury or Illness, Texas Department of Insurance. www.tdi.texas.gov The insurance carrier assigns a claim number to the case, determines whether the claim is eligible for workers’ compensation, and notifies the 1694489 – McGraw-Hill Higher Education (US) © Page 387 employer. This determination is either an Admission of Liability, stating that the employer is responsible for the injury, or a Notice of Contest, which is a denial of liability. The worker must be informed of the outcome within a given number of days. If the employee is eligible for compensation for lost wages, checks are sent directly to him or her, and no income taxes are withheld from the payments. If the claim is denied, the employee must pay all medical bills associated with the accident. These charges may be submitted to the individual’s own health insurance carrier for payment, along with the denial letter from the workers’ compensation carrier. Termination of Compensation and Benefits BILLING TIP Workers’ Compensation Global Periods Many workers’ compensation plans do not follow Correct Coding Initiative global periods. Contact the carrier to learn its global periods and get instructions on using modifiers. Temporary partial and temporary total disability benefits cease when one of the following occurs: The employee is given a physician’s release authorizing a return to his or her regular job. The employee is offered a different job by the employer (not the same job as before the injury) and either returns to work or refuses to accept the new assignment. The employee has exhausted the maximum workers’ compensation benefits for the injury or illness. The employee cannot work due to circumstances other than the work-related injury (for example, the individual is injured in a vehicle accident that results in an unrelated disability). The employee does not cooperate with request for a medical examination. (Medical examinations determine the type and duration of the disability and the relationship of the injury to the patient’s condition.) The employee has returned to work. The employee has died. (Death benefits go to survivors, however.) Appeals Individuals may appeal workers’ compensation decisions. The first step in the appeal process is to request mediation. A mediator is an impartial individual who works with both parties to obtain a satisfactory resolution. If mediation efforts on behalf of the injured employee fail, a hearing may be requested. A hearing is a formal legal proceeding. A judge listens to both sides and renders a decision, referred to as an order. If the employee is not satisfied with the judge’s decision, the claim may be appealed at higher levels, for example, at a workers’ compensation appeals board or, after that, at a state supreme court. Billing and Claim Management BILLING TIP 1694489 – McGraw-Hill Higher Education (US) © Page 388 Turnaround Times Track the date a workers’ compensation claim is filed. Insurance carriers must pay workers’ compensation claims within an amount of time, usually thirty to forty-five days, depending on the state. If the claim is not paid within the time specified, the claimant may be eligible for interest on the payment, or a late fee may apply. Workers’ compensation claims require special handling. The first medical treatment report on the case must be exact. If it is not, future treatments may appear unrelated to the original injury and may be denied. When a patient makes an appointment for an injury that could have occurred on the job, the scheduler asks whether the visit is work related. If the answer is yes, pertinent information should be collected before the office visit: Date of injury Workers’ compensation carrier Employer at time of injury Patient’s other insurance The medical insurance specialist contacts the workers’ compensation carrier for authorization to treat the patient before the initial visit. Note that the practice management program (PMP) captures workers’ compensation and injury-related information when the patient’s injury case record is created and updated. COMPLIANCE GUIDELINE Maintain Separate Files A separate file or case number should be maintained for each workers’ compensation case, even if the individual is an established patient. There are no universal rules for completing a claim form. Some plans use the HIPAA 837 or the CMS-1500, and other plans have their own claim forms. Although the specific procedures vary depending on the state and the insurance carrier, the following are some general guidelines: Providers must accept payment from the insurance carrier as payment in full. Patients or employers may not be billed for any of the medical expenses. A separate file must be established when a provider treats an individual who is already a patient of the practice. Information in the patient’s regular medical record (non–workers’ compensation) must not be released to the insurance carrier. The patient’s signature is not required on any billing forms. The workers’ compensation claim number should be included on all forms and correspondence. Use the eight-digit format when reporting dates such as the date last worked. HIPPA/HITECH TIP 1694489 – McGraw-Hill Higher Education (US) © HIPAA 837 Not Required The HIPAA mandate to file claims electronically does not cover workers’ compensation plans. The National Uniform Claim Committee (NUCC) has recommended the following information for completing a CMS-1500 workers’ compensation claim: THINKING IT THROUGH 12.4 Page 389 1. Anna Ferraro has an accident at work when the arm of her office chair gives way. She is covered by her employer’s insurance. She is also a Medicare beneficiary. Should the claim connected with the accident be filed with her employer’s workers’ compensation carrier or with Medicare? 12.5 Disability Compensation and Automotive Insurance Programs Disability compensation programs do not reimburse policyholders for healthcare charges. Instead, they provide partial reimbursement for lost income when a disability—whether work related or not—prevents the individual from working. Benefits are paid in the form of regular cash payments. Workers’ compensation coverage is a type of disability insurance, but most disability programs do not require an injury or illness to be work related in order to pay benefits. To receive compensation under a disability program, an individual’s medical condition must be documented in his or her medical record. The medical record often serves as substantiation for the disability benefits, and an inadequate or incomplete medical record may result in a denial of disability benefits. The more severe the disability, the higher the standard of medical documentation required. For this reason, an accurate and thorough medical record is of primary significance in disability cases. 1694489 – McGraw-Hill Higher Education (US) © Private Programs Employers are not required to provide disability insurance. Many companies provide disability coverage to employees and pay a substantial amount of the premiums, but others do not. Federal or state government employees are eligible for a public disability program. Individuals not covered by employer- or government-sponsored plans may purchase disability policies from private insurance carriers. Many individuals covered by employer-sponsored plans or private policies are also covered by a government program, such as Social Security Disability Insurance (SSDI). In these cases, the employer or private program supplements the government-sponsored coverage. Government Programs The federal government provides disability benefits to individuals through several different programs. The major government disability programs are: Workers’ compensation (covered earlier in the chapter) SSDI Supplemental Security Income (SSI) Federal Employees Retirement System (FERS) or Civil Service Retirement System (CSRS) Department of Veterans Affairs disability programs SSDI The Social Security Disability Insurance (SSDI) program is funded by workers’ payroll deductions and matching employer contributions. It provides compensation for lost wages due to disability. The Federal Insurance Contribution Act (FICA) authorizes payroll deductions for the SSDI program. Page 390 The definition of disability used by the SSDI program and found in Section 223(d) of the Social Security Act lists the specific criteria that must be met: The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or, which has lasted or can be expected to last for a continuous period of not less than twelve months. The SSDI program defines the categories of disability that are eligible for coverage. These are: Presumptive legal disability, which includes cases that are specifically listed in the Social Security disability manual Cases with more than one condition that together meet the disability standards Cases in which individuals cannot return to their former positions and cannot obtain employment in the local area Individuals also have to meet certain other criteria to be eligible for disability benefits from the SSDI program. The following individuals are eligible: A disabled employed or self-employed individual who is under age sixty-five and has paid Social Security taxes for a minimum number of quarters that varies according 1694489 – McGraw-Hill Higher Education (US) © to age An individual disabled before reaching age twenty-two who has a parent receiving Social Security benefits who retires, becomes disabled, or dies A disabled divorced individual over age fifty whose former spouse paid into Social Security for a minimum of ten years and is deceased A disabled widow or widower age fifty years or older whose deceased spouse paid into Social Security for at least ten years An employee who is blind or whose vision cannot be corrected to more than 20/200 in the better eye, or whose visual field is 20 degrees or less, even with a corrective lens After an application for SSDI has been filed, there is a five-month waiting period before payments begin. Individuals receiving SSDI may apply for additional Medicare disability benefits twenty-four months after they become disabled. SSI Supplemental Security Income (SSI) is a welfare program that provides payments to individuals in need, including individuals who are aged, blind, and disabled. Eligibility is determined using nationwide standards. A person whose income and resources are under certain limits can qualify even if he or she has never worked or paid taxes under FICA. Children under age eighteen who are disabled or blind and in need may also qualify. The basic benefit is the same nationwide, and many states add money to it. Federal Worker Disability Programs The FERS program provides disability coverage to federal workers hired after 1984. Employees hired before 1984 enrolled in the CSRS. The FERS program consists of a federal disability program and the Social Security disability program. The two parts of the program have different eligibility rules, and some workers qualify for FERS benefits but not for SSDI benefits. If a worker is eligible for both, the amount of the SSDI payment is reduced based on the amount of the FERS payment. The CSRS criteria of disability are not as strict as the SSDI criteria. CSRS determines that a worker is disabled if he or she is unable “because of disease or injury, to render useful and efficient service in the employee’s current position and is not qualified for reassignment to a similar position elsewhere in the agency.” Unlike the SSDI Page 391 criteria, the CSRS criteria do not specifically mention the duration of the medical condition, although it may be expected to continue for at least a year. To qualify, a worker must have become disabled during the course of his or her federal career and must have completed at least five years of federal civilian service. Employees who are eligible for CSRS benefits are able to retain their health insurance coverage through the Federal Employee Health Benefit Program. Veterans Programs The Department of Veterans Affairs (VA) provides two disability programs to former armed services members: the Veteran’s Compensation Program and the Veteran’s Pension Program. Certain veterans may qualify to receive benefits from both. The Veteran’s Compensation Program provides coverage for individuals with permanent and total disabilities that resulted from service-related illnesses or injuries. In order for a veteran to be eligible for benefits, the disability must affect his or her earning capacity. 1694489 – McGraw-Hill Higher Education (US) © The Veterans Pension Program provides benefits to veterans who are not and will not be able to obtain gainful employment. The disability must be service related and must be permanent and total. Preparing Disability Reports HIPPA/HITECH TIP HIPAA 837 Not Required The HIPAA mandate to file claims electronically does not cover disability claims. When a request is made for a medical report to support a disability claim, the physician or a member of the staff prepares the report by abstracting information from the patient’s medical record. It is important to thoroughly document each examination by the physician. In many cases, an incomplete or inadequate medical report leads to denial of a disability claim. The report for a disability claim should include the following medical information: Medical history Subjective complaints Objective findings Diagnostic test results Diagnosis Treatment Description of patient’s ability to perform work-related activities Supporting documents, such as X-rays, pulmonary function tests, range of motion tests, and electrocardiography (ECG) tests, should also be included when appropriate. Disability claim forms must be completed fully and accurately and must be supported by thorough and accurate medical reports. Two possible ways to bill the time spent on preparing disability and workers’ compensation claims are as follows: BILLING TIP Do not report 99455 or 99456 together with 99080 for completion of workers’ compensation claims. 1. Bill CPT code 99080 with the correct evaluation and management (E/M) office visit code. This code, which must be reported in conjunction with another service, covers the time required to complete insurance forms that convey more than a standard reporting form. 2. Bill CPT codes 99455–99456. In addition to covering medical disability examinations (initial and interval), these codes include the time required to complete 1694489 – McGraw-Hill Higher Education (US) © corresponding reports and documentation. If this service is mandated, the use of a 32 modifier is appropriate. Automobile Insurance When the medical office treats patients injured in a motor vehicle accident (MVA), the patient’s automobile insurance policy often covers the cost of the treatment. An automobile insurance policy is a contract between an insurance company and an individual for which the individual pays a premium in exchange for coverage of Page 392 specified vehicle-related financial losses. These policies provide several basic types of coverage: Personal injury protection (PIP) or medical payments (MedPay): Covers the driver and passengers of a policyholder’s vehicle. PIP, sometimes referred to as “no-fault” coverage, is insurance coverage for medical expenses and other expenses related to an MVA. Liability: Covers damages the policyholder causes to someone else’s body or property Collision: Covers damages to the policyholder’s vehicle resulting from a collision Comprehensive: Covers damages to the policyholder’s vehicle that do not involve a collision with another vehicle Additional types of coverage: Include coverage for uninsured motorists, emergency road services, rental reimbursement, and property damage Treating patients covered under an automobile insurance policy may require the medical insurance specialist to perform specific actions to receive the maximum appropriate payment, including: Coordinating claims with the insurance company that provides the patient’s vehicle insurance policy, including verifying the person’s benefits and obtaining preauthorization prior to treatment when possible Ruling out coverage under workers’ compensation by asking if the patient’s MVA was work related Properly handling lien—which are written, legal claims on property to secure the payment of a debt—to help ensure payment Filling out boxes 10b and 14 on the CMS-1500 to indicate that the patient’s condition is related to an MVA and the date of the MVA and including the accident claim number Talking with a patient’s attorney to stay informed and prepare for the possible settlement of a claim Making a copy of the patient’s health insurance card to provide the practice an alternative source of reimbursement in the event the vehicle insurance carrier does not pay for a claim or does not fully cover it The laws and guidelines surrounding vehicle insurance policies vary by state. Medical assistants learn and follow the policies of the state under which the patient is covered. Policies also vary by type of insurance plan, including fee-for-service and capitation plans, among other types. All of these factors, including the appropriate coordination of benefits, are considered in filing claims for the treatment of a patient injured in a motor vehicle accident. 1694489 – McGraw-Hill Higher Education (US) © Subrogation When working with workers’ compensation or liability/automotive claims, medical insurance specialists should be aware of the payers’ subrogation rights. Subrogation refers to actions an insurance company takes to reco 1694489 – McGraw-Hill Higher Education (US) ©



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