Office of Risk Management Annual Conference Workers Compensation Sedgwick: Joe Valentino Director of Claims WC Office of Risk Management: Karen Jackson Claims Manager - WC Office of Risk Management Annual Conference What is Workers Compensation? Any injury, occupational disease, or cumulative trauma sustained and/or originating in the course and scope of the employment.
A legal remedy whereby an employee who is injured on the job is automatically entitled to certain benefits. The benefits can include medical care for the injury, indemnity wage benefits, vocational rehabilitation services, and/or death benefits. Office of Risk Management Annual Conference Snapshot of Workers Comp Today Currently there are approximately 2,450 open and active workers compensation claims for State of LA employees. Current outstanding money set aside for all open workers compensation claims is
$132,137,003.00 Office of Risk Management Annual Conference Reporting A New Claim http://www.laorm.com/reporting New claims are reported through Claims Capture system and the links and information are available on the website. https://sedgwickcms.claimcapture.com/ Office of Risk Management Annual Conference http://www.laorm.com/reporting
Office of Risk Management Annual Conference https://sedgwickcms.claimcapture.com/ Office of Risk Management Annual Conference Reporting A New Claim It is important to remember to gather as much information as possible about the details of the accident when the injury is reported.
Witness? Surveillance? Another party involved? Any Police Reports / Contact info for other parties involved? Red flags or concerns? Fraudulent activity? Does the employee have another job as well? Any prior accidents or injuries? *If in doubt as to whether an injury is considered workers compensation or not, it is best to report the injury and let the professional make the determination on compensability based on the information available.
Office of Risk Management Annual Conference Reporting a New Claim 1. Once the injury is reported by the employer through Claim Capture, it is sent over to Sedgwick electronically. 2. Sedgwick Team Leads check the new claim inbox daily and assign the new claims to an examiner. 3. Once the examiner receives the new claim, they will make contact with the injured worker, the employer, and the medical provider (If available) within 24 hours of receipt of the new claim. Office of Risk Management Annual Conference
Drug Testing Policy All Agencies are required to obtain a drug test when a new workers' compensation claim is being reported. *There is a separate Drug Testing Policy presentation available that will go into specifics and allow for a question and answer session following this presentation. Office of Risk Management Annual Conference Initial Medical Treatment It is permissible for the employee to seek medical attention immediately if they choose.
There is no need to wait for a claim number to be provided by Sedgwick before seeking medical care. The employee does have the right to chose their own Physician. If the injured worker pursues a physician of their choice, they should sign the Choice of Physician form. This can be given to the injured worker initially by the employer. It will also be mailed out to them by Sedgwick in the initial work comp packet sent on all claims. Send the Physicians Modified Work Information Sheet with the employee to the medical provider. Office of Risk Management Annual Conference Office of Risk Management Annual Conference
Billing Information Mailing Address: Sedgwick P.O. BOX 14775 Lexington, KY 40512 Fax: 859-225-2000 Main Office Phone: 225-368-3500 Office of Risk Management Annual Conference Subrogation There may be incidents / accidents where another party or multiple parties are involved. In these situations Sedgwick may be able to pursue the other
parties and recover money back from parties at fault. Examples: Slip and Fall Motor Vehicle Accidents Exposure to chemicals / substance from contractors Defective Machinery or Parts Office of Risk Management Annual Conference
Subrogation It is important to recognize this potential when a new accident occurs. By doing so we are able to timely secure the information initially when the accident occurs. Things to look for include: Obtain all other parties names and contact information Get copies of police report / contracts / Surveillance video Secure any witness names and contacts Secure any equipment or machinery that was involved
*You should provide this information to the Sedgwick examiner as soon as possible as this will assist with the initial investigation. Office of Risk Management Annual Conference Second Injury Fund What is the Second Injury Fund? The fund is a State agency which reimburses employers or, if insured, their insurance carriers for part of the workers compensation costs in certain instances when an employee with a pre-existing permanent partial disability / qualifying condition is injured on the job. What is a pre-existing permanent partial disability?
Any permanent condition, whether congenital or due to injury or disease that constitutes a hindrance or obstacle to obtaining employment or re-employment if the employee should become unemployed. Office of Risk Management Annual Conference Second Injury Fund Basic requirements to qualify for second injury fund recovery: - The employee must have a pre-existing permanent partial disability as listed and defined by R.S. 23:1378(F) that is an obstacle in obtaining employment. - The employer must establish they had actual knowledge of the employees
pre-existing disability PRIOR to the subsequent injury. 1. It is important for the employer to provide this information to the examiner. 2. It is important to work with Sedgwick and respond timely when contacted about an affidavit or other SIF information. - The employee must sustain a subsequent work injury that results in liability for workers compensation. - The employer or carrier must file notice of claim for second injury fund within 52 weeks after the first payment of benefits. Office of Risk Management Annual Conference Second Injury Fund The Impact of Second Injury Fund on the file:
- If we can successfully get second injury established we are entitled to full reimbursement of medical and indemnity payments made (after the applicable deductible is met) and therefore resulting in significant cost savings to the employer. $4.2 MILLION DOLLARS was recovered from the Second Injury Fund in 2015. Office of Risk Management Annual Conference Transitional Duty *Transitional return to work is employment which allows the injured worker to return to work at the agency where they were injured within the restrictions determined by the physician until they are capable or returning to their full duty job.
- ORM requires that all agencies begin offering transitional return to work options, effective 10/1/2014, to injured employees who have been released to return to work with restrictions by their physician. - This is an auditable category that will be included on the loss prevention audits for the 2016 fiscal year Office of Risk Management Annual Conference Transitional Duty
Benefits of Transition Return to Work Program: 1. 2. 3. 4. Cost savings You are going to pay for the employee to sit out of work at home at full indemnity rate when they are out. Accommodating restricted work allows the employee to earn wages at work and reduce indemnity payments. Motivation Statistically, the longer an injured worker remains off work, the less likely they are to ever return to their pre-injury job.
Assisting your employee The program is designed to benefit the injured worker in their transition back from injury to their normal job. This allows them the opportunity to not lose touch with the workforce and their daily routine, and have a smoother transition back to full duty work which reduces the chances of re-injury. Retain qualified employees within the agency. Office of Risk Management Annual Conference Transitional Return to Work Specialist Sedgwick and ORM have a dedicated return to work specialist who is available to assist with any transitional duty questions or to discuss individual cases as needed. Her contact
information is below. Jennifer Bruhl Phone: 225-368-3417 Fax : 225-368-3490 Email: [email protected] Office of Risk Management Annual Conference Communication Communication between the Agencies and Sedgwick examiners is crucial for success. It is imperative that Sedgwick be advised of work status changes as soon as they occur: 1.
2. 3. 4. Employee goes off work Employee returns to work transitional duty Employee returns to work full duty Employee retires / applies for disability Office of Risk Management Annual Conference Communication Examples: 1. An employee may return to work and never inform the examiner who could still be sending checks
to the claimant, resulting in overpayment. 2. An employee reports a claim and does not lose time from work initially. 7 days later the employee calls in to work and says his injury is worse and he cannot come in. The adjuster is never notified that the employee went off work by the injured worker or the employer. Then, the injured worker does not get paid timely for his lost wages and the examiner is unable to investigate and confirm the compensable lost time. *It is important to remember that benefits are due to the injured worker within 14 days after employer or TPA has knowledge of lost time. 3. An employee selecting a retirement package or disability without the examiner being notified can
affect the accuracy of benefits due to the employee. **Untimely notification of work status changes and information can lead to over / under payments of Indemnity, frustrate the claimant, and lead to expensive penalties and fees in litigation.** Office of Risk Management Annual Conference Sedgwick Contacts Director of Claims WC Joseph Valentino (225)-368-3479 Claims Team Leads: Russell Smith: (225) 368-3461 Jeffrey Gautreau: (225) 368-3506
Leah Ford : (225) 368-3430 Kala Crowe: (225)-368-3489 Main Office Number (225)-368-3500 Fax Number (859)-225-2000 Office of Risk Management Annual Conference Questions? ?????????????????????????????????????????? Question and Answer session ??????????????????????????????????????????
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