In This Issue:
- Workers’ Compensation Claims and Your Bottom Line
- A Word From State Fund's President
- Medical Treatment: It's in the Network
- A Guide to Disability Benefits
- Putting Your Policy to Work: Your Core Responsibilities
- Return to Work: Better Outcomes for You and Your Injured Employees
- Fighting Fraud: What We Do, and What You Can Do
- Where to Go for Help
- 11 Ways You Can Control Your Workers' Comp Costs
- What You Need to Know About Reporting a Claim

Workers’ Compensation Claims and Your Bottom Line

When employees experience a job-related injury or illness, they may file a workers’ compensation claim and receive medical care and other benefits to help them recover. As an employer, a claim can impact your productivity and business costs. But claims don’t have to be a sore subject. They present an opportunity to make a positive difference—in controlling your costs, strengthening your relationship with employees, and implementing sound practices for the future.

At State Fund, we want to help you master good everyday safety and claims habits in the workplace. Safer work environments experience fewer claims, and a working knowledge of how to handle a claim—from reporting an injury to arranging medical treatment to returning an injured employee to work—can give you a leg up in achieving successful outcomes.

A big reason to stay on top of your claims is that they influence the cost of your workers’ compensation policy. The higher the projected claims are for your industry classification, the higher your industry’s base rates will be.  Your company’s own claims history also may result in additional debits or discounts—one such factor is your experience modification, a premium adjustment based on how your company’s loss history compares to the industry’s average. .

In recent years the average cost of a claim in California has been on the rise, driven primarily by medical cost inflation. It’s all the more reason to invest in claims awareness and management.

[Top]

A Word From State Fund's President

Our first goal at State Fund is to help you reduce the number and severity of injuries in your workplace. When injuries do happen, our goal is make sure employees receive the most effective care so they can get back to their life’s pursuits, including their job, as quickly as they can.

Helping you through the claims process is important work. As part of that undertaking, we want to you better understand the claims function in workers’ compensation. The more you know, the more you can control your costs and achieve good outcomes for your business and your injured employees.

I hope that you enjoy this claims-focused issue of COMPonents and that you put some of the information here to good use. Thank you for your business.

Tom Rowe
President and CEO

[Top]

Medical Treatment: It’s in the Network

On workers’ compensation claims, injured employees are entitled to receive medical care that is reasonable, necessary, and supported by evidence-based treatment guidelines. These guidelines are used by insurance companies (including State Fund) to evaluate requests for medical treatment—a process known as Utilization Review.

This process applies to accepted claims, and when a claim form is filed but the liability decision is delayed pending investigation.  We are required to authorize medical treatment up to a limit of $10,000 until the claim is accepted or rejected.

Insurers may also set up their own network of medical providers to treat workers’ compensation injuries. The State Fund Medical Provider Network (MPN) is a comprehensive statewide network of doctors and medical facilities with expertise in occupational health and workers’ compensation. When you direct your injured employees to providers within the State Fund MPN, State Fund is able to maintain medical control for the life of the claim and achieve the cost efficiencies of in-network providers. This gives you the chance to achieve a couple of important outcomes:

• Your employees benefit from effective, coordinated medical treatment from local doctors and specialists.
• You benefit  from claims cost savings today that can result in lower premiums for your business’s workers’ comp policies in the future.

To put the State Fund MPN in effect in your workplace, you just need to follow a few simple procedures:

1. Comply with requirements for notifying employees about the MPN (see related article on employer responsibilities).
2. Choose an MPN physician and write the physician’s contact information on the legally mandated notice that you post in your workplace.
3. When an employee notifies you of a work-related injury, ensure that an MPN physician performs an initial medical evaluation within three business days.

[Top]

A Guide to Disability Benefits

In addition to medical treatment, workers’ compensation insurance provides benefits to employees whose job-related injuries result in disability and lost earnings. Here’s a look at the different kinds of disability benefits.

[Top]

Putting Your Policy to Work: Your Core Responsibilities

You must follow certain procedures for (1) notifying your employees about workers’ compensation and (2) responding to workplace injuries. If you need any of the forms listed here or have any questions about your compliance, contact our Customer Service Center at (877) 405-4545.

Required Employee Notices
These notices tell employees about their workers’ compensation rights and how to get medical treatment for workplace injuries. If you fail to follow these notification mandates, you could be subject to state-imposed fines. Also, State Fund could lose medical control of a claim, which may result in higher claims costs.

• Post the Notice to Employees posting notice (form 13708) conspicuously in the work area (and post Spanish form 13709 if you have Spanish-speaking employees).
• Provide the New Employee’s Guide to Workers’ Compensation (form 13286) and the Employee’s Guide to the State Fund Medical Provider Network (MPN) (form 13176) brochures to all new employees when you hire them. You also must provide the MPN brochure to all employees before you implement the MPN in your workplace and to any employee who reports a work-related injury.
  

When an Injury Occurs

•  Make sure your injured employee receives medical treatment.
• Give your injured employee the DWC-1 claim form (form 3301) and the MPN brochure (form 13176).

Report the injury promptly to the State Fund Claims Reporting Center at (888) 222-3211. We will help you complete the required Employer’s First Report of Injury (form 3067).

[Top]

Return to Work: Better Outcomes for You and Your Injured Employees

When one of your employees is missing work because of a workers’ compensation injury, you may want to consider a “return to work” option. Under return to work, you bring injured employees back to work in either a transitional job, or in their regular job with some type of accommodation, as soon as medically feasible.

The outcome is win-win: Numerous studies have shown that employees who can return to work more quickly experience faster, more successful recoveries. And for your business, minimizing time losses can reduce claims costs and help you maintain productivity.

If you need help returning injured employees to your workplace, we’ve got you covered. State Fund’s Return to Work Program can offer you dedicated resources and support to put a plan in motion.

[Top]

Fighting Fraud: What We Do, and What You Can Do

Fraud can take several forms in workers’ compensation, but the bottom line is the same: Someone is trying to cheat the system to gain an unfair advantage. Claims fraud can happen when employees try to obtain benefits to which they’re not entitled, or when medical practitioners and other service providers falsify or distort their billing practices.

As an employer, you can make a difference in preventing fraud. Educate your employees about workers’ compensation so they know the benefits for legitimate claims and the penalties for fraudulent ones. You can also be on the lookout for fraud and report suspicious activities.

At State Fund, we maintain a Special Investigation Unit that is dedicated to rooting out fraud and reporting cases to law enforcement. Effectively fighting fraud is an important way we keep insurance costs down and protect the interests of employers, employees, and providers who play by the rules. You may reach our toll-free fraud hotline at (888) 786-7372.

[Top]

Where to Go for Help

For reporting an injury or illness: State Fund’s Claims Reporting Center is available 24/7 at (888) 222-3211. The sooner you call to report the claim, the sooner we can advise you and your injured employee on proper courses of action, including arranging medical treatment.

For answers about your State Fund policy and workers’ comp insurance: Call the State Fund Customer Service Center at (877) 405-4545. If you are represented by an insurance broker, you may also contact your broker for assistance.

For information about the State Fund Medical Provider Network: Contact the MPN Help Desk at (866) 436-0204 or scifmpn@scif.com. To find an MPN care provider, go to www.statefundca.com and select “Find a Doctor.”

For details about a specific claim: Contact the claim’s assigned claims adjuster. The adjuster to determines the appropriate coverage and keeps in touch with you, your injured employee, and the medical provider.

For fast information anytime: State Fund Online is a great way to get a closer look at your workers’ compensation policy and claims information. In addition to claims updates, you can submit payroll reports and payments online, print certificates of insurance, and more. If you haven’t registered yet, go to www.statefundca.com and look for the State Fund Online box at the right.

[Top]

11 Ways You Can Control Your Workers’ Comp Costs

Whether or not you currently have any active claims, you should always be focused on controlling your workers’ compensation costs. Here is a quick summary of some things you can do to make a difference in your workplace.

• Hire with care. Check references and review work history; consider pre-employment screening.
• Make safety a priority. Establish a safety program and enforce it.
• Fix dangerous worksite conditions.
• Train supervisors so they know their responsibilities.
• Investigate and report claims in a timely manner. Establish claims reporting procedures and let employees know how to report an injury (and provide them with the proper form).
• Exercise medical control by referring injured employees to providers that are part of the State Fund Medical Provider Network (MPN). Also, establish a strong relationship with your MPN provider.
• Show your employees you care. If an employee is injured, stay in touch.
• Implement a return to work program.
• Maintain thorough personnel records.
• Combat fraud. Let employees know all claims will be investigated and improper claims fought.
• Review your claims history. Look for any trends or red flags.

[Top]

What You Need to Know About Reporting a Claim

As soon as you are aware of a possible work-related injury or illness, you should take action to make sure your employee receives appropriate medical treatment and report the claim to your insurance carrier. By law, you must file a claim for every occupational injury or illness, with one exception: When the incident does not cause the employee to miss work for a full day or shift beyond the date of injury or illness, and also does not require treatment beyond the legal definition of first aid.

Reporting and Validating the Claim

You should report the injury without delay. The State Fund Claims Reporting Center is available 24/7 at (888) 222-3211. Timely reporting helps control claims costs while ensuring your employee gets prompt treatment. The legal deadline for providing your employee with the official DWC-1 claim form is within one working day of receiving notice or knowledge of the injury. You also need to file the Employer’s Report of Occupational Injury or Illness (form 3067) within five days of receiving notice or knowledge.

Reporting a claim is not an admission of liability. State Fund reserves the right to accept or deny the claim, even if the injured employee is already receiving authorized medical treatment. A key legal standard in validating the claim is whether evidence shows that the injury or illness arose out of and in the course of employment.

Can the Treatment Be First Aid?

When treatment for a minor injury meets specific standards, it may be classified as “first aid,” which means you do not need to report it as a claim (or have it count as a claim on your loss record).

You may not designate a workplace injury as first aid—and you must report a claim—if either of the following occurs:

• Medical care goes beyond a one-time treatment and follow-up visit.
  
• The injury causes an employee to lose any time from work beyond his or her shift.

[Top]