A Workers’ Compensation Primer for the Medical Tourism Industry

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I thought for my official thirtieth post, I would write a primer on workers’ compensation for the medical tourism industry, so that if any medical tourism facilitators or medical tourism companies, destinations, etc., wanted to get into the workers’ compensation arena, they would have a basic understanding of some of the terminology found in workers’ compensation.

I carefully avoided using any terms that were too technical, too legal, or too involved with Insurance and related aspects of workers’ compensation. But I also wanted to get as much information from as many sources as I can. I found glossaries from state workers’ compensation agencies in California, New York and Oregon, as well as a glossary of abbreviations from a workers’ compensation blog of a law firm in Minnesota.

So without further ado, I give you the primer on workers’ compensation terms. Study it well, there may be a test afterward.

Accident:      An event that results in personal injury to a worker.

Accident Date:     The date the accident occurred or the date of onset of occupational disease. It is usually established by a Law Judge.

Accident, Notice and Causal Relationship (ANCR):     Minimal conditions that must be met before responsibility can be assigned, usually financial, to a claim for workers’ compensation. It must be established that: a) a work-related accident occurred, b) the claimant notified his/her employer within time limit, and c) that a causal relationship exists between the accident and a resulting injury or disability.

AOE/COE:     see below

Arising out of and in the Course of Employment:     An injury that “arises out of” is one that results from a hazard of the employment, while an injury “in the course of employment” is one that occurred at a time, place and under circumstances related to the employment. Note: Claims have been disputed over this issue, depending upon the definition of “in the course of employment”. An example of such a dispute would involve whether or not, an injury suffered while walking to work from a private parking lot to the place of employment is covered, while an injury suffered while walking to work in a parking lot owned by the employer is covered. There are some issues with whether those injuries are covered, even though the parking lot is part of the employer’s property, the lot may not be controlled by them, and therefore not subject to the “in the course of employment” criteria.

Average Weekly Wage (AWW):     Wage used to calculate total disability benefit rate for most claimants. Defined as 1/52 of injured worker’s average annual earnings.

Cause of Accident:     Object, substance or condition that directly contributed to the occurrence of an accident.

Claim:     A request for worker’s compensation for a work-connected injury, occupational disease, disablement, or death.

Claimant:     A person who files a claim for occupational disease or injury benefits. See my last post, By Any Other Name, for a discourse on the faux dichotomy between claimant and patient.

Claims Adjuster:     Insurer representative who processes a claim filed by an injured worker. See also, claims examiner.

Claims Examiner:     see Claims Adjuster

Compensable Injury:     An accidental injury, arising out of and in the course of employment requiring medical services or resulting in disability or death.

Controverted Claim:     A claim challenged by the insurer on stated grounds.

Date of Injury (DOI):    see Accident Date

Disability:     Sometimes confused with impairment (see Impairment). Disability represents how an impairment combined with person’s age, educational background, vocational background and other factors affect an injured workers’ ability to return to work.

Employee:     A person whose work activities are under the control of an individual or entity.

Employer:    see also Insured Employer:     Any person who contracts to pay for work or services, with the right to direct or control the work or services of a person.

Exclusive Remedy:     The premise on which the Workers’ Compensation system is based: workers give up the right to sue the employer in exchange for medical care and for payment for their injuries.

First Report of Injury (FROI):     A specific form that an employer must fill out following an injury.

Future medical:    On-going right to medical treatment for a work-related injury.

Hearing:     Legal proceeding in which a worker’s compensation judge discusses the issues in a case or receives information in order to make a decision about a dispute or a proposed settlement.

Impairment:     A medical term often confused with disability. Impairment is what is anatomically or physically wrong with an individual and is a means where the medical care provider assigns a numerical rating for whatever type of bodily function has been lost.

Impairment Rating:     A percentage estimate of how much normal use of a person’s injured body part has been lost. Ratings are determined based on guidelines published by the AMA.

Independent Medical Exam (IME):     A medical examination of an injured worker by a physician other than the worker’s attending physician performed at the request of the insurer.

Independent Medical Examiner (IME):     Individual who performs the independent medical examination. Also called a qualified medical examiner in some states, namely California.

Insured Employer:     An employer who has workers’ compensation insurance to cover work injuries of subject workers.

Insurer:     An insurance company authorized to transact workers’ compensation insurance, a self-insured employer (see Self Insured), or a self-insured employer group. Most states in the US allow commercial insurance companies to sell workers’ compensation insurance policies in their states, but a few are monopolistic states, such as North Dakota, Ohio, Washington and Wyoming. The competitive states also report their policy and claims and other data to advisory organizations (formerly called rating bureaus) such as the National Council on Compensation Insurance (NCCI) and certain state-run rating bureaus who determine insurance rates for workers’ compensation insurance based on data submitted to these organizations on a pre-determined schedule and under certain reporting requirements.

Lost time:     A period of total wage loss and loss of earning capacity, beyond the statutory waiting period (see Waiting Period), caused by the claimant’s work-connected disability. In workers’ compensation, lost time claims are the claims most likely to require additional medical care and treatment beyond what is generally provided for claims that are medical-only (see Medical Only).

Maximal (Maximum) Medical Improvement (MMI):     An assessed condition of a claimant based on medical judgment that (a) the claimant has recovered from the work injury to the greatest extent that is expected and (b) no further change in his/her condition is expected. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant.

Medical Fee Schedule:     A schedule, usually established by the state workers’ compensation agency, such as New York’s Workers’ Compensation Board, of the charges and fees for medical treatment and care furnished to workers’ compensation claimants.

Medical-legal report:     A report written by a doctor that describes the claimant’s medical condition. They are written to help clarify disputed medical issues.

Medical Only:     A workers’ compensation claim that does not result in time loss or permanent disability but requires only medical treatment.

Medical Provider Network (MPN):     An entity or group of health care providers set up by an insurer or self-insured employer to treat workers injured on the job.

Modified Work:     A modification to an injured worker’s job duties or work schedule to accommodate the physical limitations resulting from the injury or disease.

National Council on Compensation Insurance (NCCI):     An association of workers’ compensation insurers which serves as the workers’ compensation rating organization in about two-thirds of US states. The group establishes standards for use in rate making, develops policy forms, collects statistics, and provides statistical support and services.

Objective findings:     The indications of injury or disease that are measurable, observable, and reproducible, used to establish compensability and determine permanent impairment.

Occupational Disease:     A disease or infection, arising out of and occurring in the course and scope of employment. It is caused by substances or activities to which an employee is not ordinarily subjected or exposed other than during employment and requires medical services or results in disability or death. To be considered an occupational disease, there must be some recognizable link between the disease and some distinctive feature of the worker’s job.

Occupational Health and Safety Administration (OHSA):     Federal agency that oversees workplace safety and health in federal offices and in states without state OSHA programs.

Occupational Illness:     Any abnormal condition or disorder, other than one resulting from an occupational injury, caused by exposure to environmental factors associated with employment; it includes acute and chronic illnesses or diseases which may be cause by inhalation, absorption, ingestion or direct contact.

Occupational Injury:     Any injury, such as a fracture, sprain, amputation, etc., which results from a work accident or other exposure involving a single accident in the work environment.

Permanent Impairment:     The permanent loss of use or function of a body part or system due to a compensable injury.

Permanent Partial Disability (PPD):    Permanent loss of use or function of any portion of the body. It is the benefits a worker receives when the injury partially limits the kinds of work they can do or their ability to earn a living.

Permanent Total Disability (PTD):     The loss of use or function of any portion of the body in combination with any preexisting disability that permanently prevents the worker from regularly performing gainful and suitable work. Also the benefits a worker receives when they are permanently unable to work.

Professional Employment Organizations (PEO):     Term used to refer to worker leasing companies. Workers are leased out to companies for the purposes of not having to pay benefits and wages directly to workers, and are hired by the leasing company so that the worker’s employer is considered the leasing company, and not the company who leases them.

Return to Work (RTW):     Programs implemented to return an injured worker to his place of employment as soon as medically possible.

Self-Insurance:     An employer or group of employers may assume the liability for the payment of workers’ compensation benefits to employees by depositing securities or a surety bond in an amount required by a state workers’ compensation agency.

Self-Insured:     Also called self-insured employer. An employer that directly assumes financial and processing responsibility for workers’ compensation benefits rather than purchasing an insurance policy. A self-inured employer must meet certain financial qualifications and be certified by the appropriate state workers’ compensation agency.

Temporary Partial Disability (TPD):     Means that the injured worker is only able to do some type of limited work for a short period of time and that further recovery is expected. It is also the payment for wages lost when a worker is only able to perform modified or part-time work because of a compensable injury.

Temporary Total Disability (TTD):    Means that a person is unable to do any type of work for a temporary period of time. Workers’ compensation payments are usually paid when the injured worker is out of work.

Third Party Administrator (TPA):     A company contracted by a self-insured employer or insurer to administer its workers’ compensation claims. Also called Claims Administrators, Claims Management firms, or service companies.

Vocational Rehabilitation:     Benefits given to injured workers who cannot return to their previous employment due to their permanent disability. The worker is provided with job training and job placement in jobs suitable for persons with limitations.

Waiting Period:     Depending upon individual state law, the waiting period is the period before payments for workers’ compensation benefits begin. In some states, this could be three days, or as in the case of New York, seven days, or maybe ten in other states.

Workers’ Compensation Board (WCB):     State agency in some states, such as New York, that administers Workers’ Compensation laws, as well as other related laws such as Volunteer Ambulance Workers’ Benefit and Volunteer Firefighters’ Benefit laws, and the Disability Benefit law.

Workers’ Compensation Law Judge:     In some states, also called a Workers’ Compensation Administrative Law Judge or Administrative Law Judge. An official of the state agency that administers workers’ compensation laws in that state who holds hearings to determine claims and makes decisions and determinations of the claim.

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About Transforming Workers' Comp

Have worked in the Insurance and Risk Management industry for more than thirty years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. Have experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. Received my Master of Arts (MA) degree in American History from New York University, and received my Bachelor of Arts (BA) degree in Liberal Arts (Political Science/History/Social Sciences) from SUNY Brockport. I have studied World History, Global Politics, and have a strong interest in the future of human civilization in all aspects; economic, political and social. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. LinkedIn Profile: http://www.linkedin.com/in/richardkrasner Resume: https://www.box.com/s/z8rxcks6ix41m3ocvvep

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