Healthcare Rules: Get the Outline of Workers' Comp Claims Submittal


Plus, discover what the HIPAA rules allow for workers' comp

Basically workers’ compensation loss was created by each state. This is an important concept. And they're regulated and administered by state officials. So we don’t have necessarily a nationwide coverage plan for work comp. It's not like Medicare. It's not like say a commercial payer, United Healthcare that has a commercial coverage. Read this expert healthcare training article to know more.

Instead, it is a state regulated. And there are several different options. You know, first and foremost, the state can allow private insurance. So we may have payers that are capable of writing coverage policies. We might see Liberty Mutual. We might see Cigna work comp. We might see Kemper, various different private insurances selling and covering and addressing workers' comp claim.

It may be a state that has a state fund exclusively. For example, North Dakota and Wyoming, all employees are covered under the state fund. There isn't individual private insurance. You may have a state fund or an authorized self-insurance so we've got some states such as Ohio, Washington and west Virginia that has a state fund. Or employers can also be self-insured.

They can allow that self-insured that now accounts for about 1/3 of the traditional market premium. Most of the states that allow for employers to be self-insured for work comp have very strict healthcare guidelines that are regulated. In many cases, they have to put up several million dollars’ worth of bonds in escrow so that if they were to go bankrupt, their employees that were maybe already have an open work comp claim wouldn't be left out in the cold. So again, many of the states that allow self-insure have very strict regulations regarding the self-insured coverage.

And then there's a combination where there are state that have a state fund and there's also private insurance.

In contrast, federal employees are actually covered by the Federal Employees Compensation Act keeping in line with the healthcare rules. It is important to understand that this is irrespective of the geographic location of an injury.

So if one of your patients is a federal employee, we're talking about postal workers. Maybe they work at a federal center, et cetera. Their work comp will be covered under the federal and it supersedes that state jurisdiction.

So regardless that they were maybe, you know, injured in the state of Texas if they're a federal employee, they're going to be covered by the federal, the FECA. And it is actually administered by the OWCP according to the healthcare rules. And so that's very important to understand.
Maritime employees for those states that have some water basis, they’re covered by the Long-Sherman’s and Harbor Workers' Comp Act and that is also administered by OWCP.

In contrast, railroad employees are covered in a little bit different, they're actually covered under the Federal Employee Liability Act, get this, of 1908. And it really differs from standard workers' compensation coverage.

So again it's irrespective out what state that they were injured in. But also the medical expenses are processed by the Railroad Medical Coverage policy. So the commercial policy that covers railroad employee’s general health insurance oftentimes is processing the work comp claims.

So you need to be careful that occasionally, the work comp claims will be processed with a copay and that's incorrect as per HIPAA rules. And so, you need to contact that at gesture so that the railroad will pay for that and it's not a patient responsibility.

So again, work comp is not included in the definition of a health plan. It is specifically excluded. So as that, covered entity may use or disclose protected health information, the PHI to the extent that it's required by law.

Again, the another reg is that they may disclose the PHI as authorized or to the extent necessary to comply with laws relating to work comp or other similar programs that provide benefits for work related injuries. So again, we have a right to disclose patient information such as our documentation to a work comp carrier.

The HIPAA privacy rule doesn’t apply to entities that are either work comp insurers, work comp administrative agencies or employers except to the extent that they may otherwise be covered entities as per HIPAA rules.

The privacy rule permits covered entities to disclose PHI to work comp insurers, state administrators without the individual’s authorization. And again, that is to the extent the disclosure is required by the state. Again, for our purposes of attaining any payment from any healthcare provider to the injured or ill worker.

Disclosures without individual authorizations, again, we have that right without to disclose to work comp or similar programs established by law that provide benefits for work related injuries. Now, with individual authorizations, we and also disclose PHI to workers' comp involved where the individual has provided his authorization to release potentially an additional information to the entity.

So again, that minimum necessary, this goes back to be cognizant of what's in your documentation particularly if you're a primary care to ensure HIPAA compliance. We certainly, if the patient is being seen for a back pain strain and the patient comes in for a sexually transmitted disease, we do not in any way, shape or form want to have that mixed together in the same note because it would not meet that criteria for a minimum necessary to disclose for that work related.

Patient’s request to restrict, they basically do not have a right under the privacy rule to restrict, that the covered entity restrict disclosure of their PHI regarding work comp purposes when we're following the law. So a patient can't say you can't send documentation about my work comp claim to the work comp carrier.

Now, in some cases, it may need be to be routed through an attorney. But in the instance they don’t have the capability to totally restrict is saying you cannot disclose.

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