Employee Paying for Workers' Comp Treatment!

I am new to the HR position in my company, and as I've stated in previous posts, our workers' comp claims were not being handled correctly before I came. I found out recently that one of our employees has a back injury (from work) for which he's been seeing a chiropractor and a physical therapist. I don't think he has told his doctors that it is workers' comp, because they have been billing his personal insurance, charging him the remainder, and he in turn has been turning his personal bills in to our company for payment.

What should I do? Am I correct in assuming that his personal insurance should NOT be covering theses costs? Do I need to make back payments to his doctors and/or insurance company?


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  • I am assuming the laws in your state are similar enough to those in mine ... I believe you must immediately file a first report of injury with your carrier, and include as much info about current treatment process. Then you or the employee could nofify his clinic that this is work comp and billings for all past treatments, and future related treatments, go to your work comp carrier. Work comp should pay the full bill, assuming they accept liability for the claim. Therefore, the clinic should be reimbursing the health insurance provider, as well as the employee for their co-pays. The employee should then reimburse the employer (if the employer did, in fact, pay for those.)

    If for some reason the work comp carrier denies the claim, then you have an even bigger mess on your hands! In any event, if it is work related, it does need to go through the work comp carrier, with all other parties reimbursed by the clinic.

  • [font size="1" color="#FF0000"]LAST EDITED ON 03-17-05 AT 09:21AM (CST)[/font][br][br]KDSPA: Welcome to the forum. You seem very positive that this employee's back situation is a W/C injury resulting from some accident. Do you have an accident report, which supports the companies knowledge of this accident with injury?

    Your words tell me you really do have a potential nightmare. If it is a ligitmate Worker's Compensation injury, then yes, your company should be paying 100% of the cost. That includes time off for treatment, time lost which resulted from the injury, milage, and medical bills. You could be totally self-insured and acting as your own carrier, but to do that you would still be filing required reports to the state. Which you don't indicate that there is any records.

    Someone in your company needs to be designated as the company representative for W/C and then get "schooled on the appropriate procedures" and the cost accounting functions set up by law.

    Trying to go back and create a W/C record/keeping may not be possible in your companies case, but the company should be considered lucky there has not been a case yet to cause penalities and fines or requirements to "Contovert the disabilities caused by the accident".

    The best thing to do would be to start with this case, keep good records and go forth to get someone assigned and educated into the W/C arena and to start from this day forward getting it done, correctly. Maybe, because the company has kept your employees safe, and when hurt, took care of their ills is the reason nobody has complained and the state W/C authority, out of your "nickers". They, evidently, do not know your company is around.

    I have been in both situations as a totally self insured and several with a third party administrator carrier, I recommend the 3rd party carrier.

    You definately need a Blessed day, today. We wish you well. The place to start is with your peer group of HR or safety people in your community, most will be happy to assist you in learning the basics and the regiment that they go through with every case, which just might fit your circumstance.

  • The situation is not quite nightmare - but it's certainly not a happy dream either! When I came on board, we had accident reports, but no one had reported them to our insurance carrier. I reported each of the cases as a "Report Only" in order to get a claim number for each incident/employee. (Our policy, I discovered, is to cover the first $1,000 of a claim and then turn it over to the insurance company if costs exceed that amount.) I've cleaned up as much of the "back-log" as possible, and I've "schooled" myself on WC so that into the future we handle these situations correctly. I DO have a claim number for this incident, so I'm not worried about the carrier covering the claim - I just want to make sure I go about cleaning up the situation as professionally (and legally) as possible! Thanks for all the input PORK & SANDRA.
  • KDSPA: Apparantly, you are totally self-insured up to $1000.00. If that is the case, then you need to pay the ee as a reimbursement or direct to any medical provider, so that you have a clean record of cost up to the $1000.00.

    With Chiropactor Services, I have found that the treatment plan never seems to be finished. The weekly adjustments or monthly adjustments will continue forever, if you do not lock the treatment plan to a specific number of treatments supported by a progression documentation and x-rays of the damaged area of the body to prove the damage has been repaired.

  • Once the ee exceeds the $1k mark and it is turned over to your carrier, do you have a specific doctor or clinic that you use to treat/diagnose work related injuries? If so, I would follow PORK's advice, do what you need to do to show that the $1k limit has been reached for your purposes, then send to the carrier and have them schedule the ee for a consultation with the W/C approved physician. The carrier needs to know the information about the ee paying for treatment so they can get this cleaned up with the docs and reimburse the insurnace company, and the ee. Once that is settled, the approved physician should be the primary for the claim, so this could change the direction of the treatment, etc. As PORK stated, chiropractors will have you come back forever. Get the ee in a treatment plan authorized by your carrier, so that they can use their network of physicians and specialists. It will be beneficial in the long run.
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