WCMP - Reference Guide

CALIFORNIA SANITATION RISK MANAGEMENT AUTHORITY

WORKERS’ COMPENSATION MANAGEMENT PROGRAM

REFERENCE GUIDE

Materials contained in this program are protected and may not be reproduced without the express, written consent of Lynch & Associates. This program, including procedures, forms, letters, reference materials and guidelines, was created for California Sanitation Risk Management Authority and may not be shared, loaned or otherwise given to any other entity, company or organization without the express, written consent of Lynch & Associates.

In the development of this program, a concerted professional effort was made to ensure the accuracy of the contents; however, no warranty is express or implied. This program should not be regarded as a substitute for the advice and counsel of an attorney.

For any questions regarding the copyright or contents of this program, contact California Sanitation Risk Management Authority. CSRMA: Workers’ Compensation Management Program Reference Guide TABLE OF CONTENTS

I. Introduction A. Program Overview B. Recommended Diary System C. Simplified Injured Employee Flow Chart D. Overview of California Workers’ Compensation System

II. Workers’ Compensation 101 A. Types of Claims B. Types of Workers’ Compensation Benefits C. Flowchart of How Claims are Handled at Bragg and Associates D. Medical Provider Network – User Guide E. Common Abbreviations F. Common Terms Used in Workers’ Compensation G. Expanded Definitions 1. First Aid Injury 2. Major Injury/Illness 3. Offer of Modified or Alternative Job 4. Permanent Disability/Permanent Impairment 5. Qualified Injured Worker 6. Settlement Of Claim 7. Supplemental Job Displacement Benefit 8. Vocational Rehabilitation H. Related Laws & Services 1. Americans with Disabilities Act 2. California’s Fair Employment and Housing Act 3. Defenses Available to the Employer Under ADA/FEHA 4. Family and Medical Leave Act 5. Job Accommodation Network (JAN) I. Frequently Asked Questions (FAQs)

Purpose This Agency has implemented a comprehensive Workers’ Compensation Management Program in order to provide Employees with the opportunity to recover quickly, minimize wage loss and maintain a level of productivity after a work-related injury or illness. The program was developed through our Joint Powers Authority, the California Sanitation Risk Management Authority (CSRMA), which coordinates the Risk Management efforts of member wastewater facilities in the State of California. The Workers’ Compensation Management Program will enable the Agencies in CSRMA to effectively manage Workers’ Compensation losses and contain the direct and indirect costs of occupational injuries and illnesses.

Procedure The Agency will provide injured Employees with the opportunity to return to work as soon as possible after an injury or illness. The Employee will complete an Initial Injury Packet with their Supervisor to thoroughly document the incident, obtain a treatment referral, and receive information about workers’ compensation and the return to work process. The injured Employee’s treating physician will be asked to play a major role in the process by providing the Agency with detailed information regarding the Employee’s physical capabilities. If the injured Employee is capable of performing the Usual & Customary position, then the Employee will be returned to work immediately. If the injured Employee is not capable of performing full duties, then the Employee’s Department will attempt to develop a Transitional Assignment by either making temporary modifications to the Usual & Customary position or identifying transitional tasks that fit within the Employee’s work abilities. The Department will work with the Employee, the Workers’ Compensation Coordinator and/or Upper Management to identify an appropriate assignment. Transitional Assignments are temporary and will be provided to injured Employees who will benefit from the rehabilitative nature of transitional work and contribute to the productivity of the Agency. Employees in Transitional Assignments will work at their regular rate of pay. Transitional Assignments are monitored periodically with the goal of returning the injured Employee to their Usual & Customary position.

Roles & Responsibilities The program is built on a team effort approach by all Employees, Supervisors, Department Managers, the Workers’ Compensation Coordinator, the General Manager and the Third Party Administrator as overseen by CSRMA. The active participation of all team players is necessary to achieve the goal of successfully returning an injured Employee to work as a healthy and productive member of the Agency.

In the event of a work-related injury/illness, the Employee will complete an Initial Injury Packet with their Supervisor. The Supervisor will ensure that the Employee receives appropriate care and assistance. The injured Employee is responsible for providing the Agency’s Workers’ Compensation Coordinator with an updated Employee Status Report after each medical appointment. The Workers’ Compensation Coordinator will review the Employee Status Report and the injured Employee’s Usual & Customary position and will work with the Employee, the Supervisor and the Department Manager, if necessary, to identify modifications or a Transitional Assignment to return the Employee to work. The Supervisor and the Workers’ Compensation Coordinator will maintain a positive and constant flow of communication with the injured Employee while helping the Employee to return to work when medically appropriate.

The Workers’ Compensation Coordinator conducts regular file reviews with the Third Party Administrator, and oversees the management and closure of Workers’ Compensation claims. If an Employee becomes permanently disabled and is unable to return to the Usual & Customary position, the Workers’ Compensation Coordinator and/or Upper Management will engage in an interactive process with the Employee to identify a Modified or Alternative placement within the Agency as available.

The General Manager oversees the entire Workers’ Compensation Management Program and ensures the integrity of the program.

This combined effort provides improved benefits to all Employees of the Agency, ensuring a prompt and healthy return to work after an injury or illness.

The calendar function in Microsoft Outlook can be used to diary workers’ compensation files. If you already use Outlook to keep your calendar, then you can either create a new calendar specifically for workers’ compensation files or you can add the diary items to your existing calendar. The primary benefit of using Outlook for your diary system is that it has windows that pop up to remind you of tasks that need to be completed.

Step One: Open Outlook Open Microsoft Outlook by clicking on the icon, or choosing it from the Start menu.

Step Two: Open the calendar function Click on the calendar icon in the Outlook Shortcuts sidebar.

Step Three: Create a workers’ compensation calendar (Skip this step if you prefer to add the workers’ compensation items to your regular calendar.) From the FILE menu, select FOLDER, then NEW FOLDER. Name the folder “WC Calendar,” or another appropriate name. The FOLDER CONTAINS drop down menu should read “Appointment Items.” The SELECT WHERE TO PLACE THE FOLDER section should have “Calendar” highlighted. Click OK. At the prompt, click YES to have a shortcut placed in the Outlook Bar (this can make your calendar easier to find later.)

Step Four: Diary items Click NEW (located below the FILE and EDIT menus) to create a NEW APPOINTMENT. Type the injured Employee’s name in the SUBJECT line. Choose the date for START TIME. Click the box next to REMINDER and select how early you want to be reminded that the task needs to be completed. In the large box below the reminder section, type in as much information as you will need. It may be as simple as typing “File Assessment.” Click SAVE AND CLOSE.

Step Five: When the reminder appears When it is time for you to do the task, a window will pop up. Click OPEN ITEM to see exactly what needs to be done. Close the opened item to return to the reminder window. At this point you can either click DISMISS and then take care of the task immediately, or you can SNOOZE the item until you are ready to handle it.

Overview: As you reach each step in the Workers’ Compensation Management Program procedures that states that you should diary for a review or other action at a later date, simply follow Step Four above to diary the task. Then you can forget about it until action is required. Please note, Outlook needs to be open for you to receive the reminders; however, if it is not open when a reminder time passes, it will remind you as soon as you open Outlook.

Em ploye e an d An Employe e Re ports Doe s Supe rvisor Incide nt/ Incide n t/ Em ploye e Comple te In jury/ NO In jury/Illn e ss to Wan t Medical De clin ation of Illn e ss Supe rvisor Tre atm e n t? Me dical Tre atme n t Occurs P acke t

YES Em ploye e Workin g Employe e to Usual & Em ploye e an d Treating P hysician Custom ary Su pe rvisor & P osition Com ple te Initial Retu rn Visits to Inju ry P acket Tre atin g P hysician

Re lease d to Usu al Re le ase d to Work Total Te m porary & Cu stomary With Re strictions Disability

Inte ractive Offe r of Modified P roce ss: P osition Transition al Assign me nt or Modifie d Usual & Cu stom ary Offe r of Alte rn ative P osition P e rm an e nt Re striction s and Re le ase d to Usual Un able to Re tu rn & Cu stom ary to Usu al & Vocation al Custom ary Re h abilitation (Date of Injury before 1-1-04)

Su pple me n tal J ob Displace me nt Ben e fit (Date of Injury on/after 1-1-04)

© 2004 Lynch & Associates/ Revision 5/2007 Page 6 CSRMA: Workers’ Compensation Management Program Reference Guide OVERVIEW OF CALIFORNIA WORKERS’ COMPENSATION SYSTEM The California workers’ compensation system is a “no fault” system. Injuries or illnesses that arise out of employment and occur in the course of employment are compensable in accordance with California law. In the event of a work-related injury or illness, the Employee must notify his or her employer as soon as possible. Injured Employees are protected from discrimination under California Labor Code Section 132(a). The workers’ compensation system was established and is closely monitored and controlled by the State of California. An employee does not require an attorney in order to receive benefits. If an employee chooses to retain an attorney, any fees for services rendered by the injured Employee’s attorney are deducted directly from the injured Employee’s benefits received through the workers’ compensation system. This Agency is self-insured for workers’ compensation through the California Sanitation Risk Management Authority. Gregory B. Bragg & Associates, Inc. administers the Agency’s workers’ compensation to ensure that the injured Employee receives all applicable benefits in accordance with California Labor Code regulations. If you have questions about workers’ compensation, contact Bragg & Associates, or the Workers’ Compensation Coordinator (see Contact Information on the following page). If you are in need of further assistance, you may contact an Information and Assistance Officer at the nearest office of the State Division of Workers’ Compensation at (800) 736-7401. This information service is free. The State of California’s workers’ compensation labor code laws govern the three parts of a workers’ compensation claim: I. Medical Treatment II. Compensation Payments for Lost Wages III. Claim Resolution I. Medical Treatment: The State of California requires the Agency to provide all reasonable and necessary medical treatment to the injured Employee. The injured Employee pays no deductible and no co-payments. All costs are paid by the Agency through Bragg & Associates for the treating physician, prescriptions, hospital charges, lab fees, therapy, equipment such as crutches, back braces, etc., as well as the injured Employee’s mileage for such appointments. If the Agency has retained a Medical Provider Network (MPN), the Agency will direct injured Employees to a medical facility within the MPN, unless the Employee has pre-designated his/her personal physician in writing prior to the Date of Injury. If an injured Employee requires a change in physician, they can select one from the MPN or contact the Workers’ Compensation Coordinator for assistance. The injured Employee should make every effort to schedule follow up appointments, examinations and physical therapy to cause minimal impact on the workday. The number of physical therapy, occupational therapy, and/or chiropractic visits may be limited in accordance with California Labor Code laws; contact Gregory B. Bragg & Associates, Inc. for more information about treatment limitations. See your Workers’ Compensation Coordinator for the Agency’s current designated medical clinic. In the event of an emergency call 911. II. Compensation Payments: The State of California requires the Agency to provide compensation to injured Employees who are disabled from work for a period of time due to a work-related injury/illness. If an Employee is unable to work for more than three days due to a work- related injury/illness, the Agency will provide the injured Employee with Total Temporary Disability payments (TTD) through the Third Party Administrator until one of the following occurs:  The treating physician releases the injured Employee back to his or her Usual & Customary position, or  The injured Employee is offered a Transitional Assignment, or  The injured Employee is offered a modification of the Usual & Customary position, or  The Employee is determined to be permanently disabled from the Usual & Customary position.  The maximum of 104 weeks of Temporary Disability Benefits is paid. Workers’ compensation will pay 2/3 of the injured Employee’s Average Weekly Wage up to the California State maximum, which changes based on the Date of Injury. In accordance with the California Labor Code, Total Temporary Disability payments will not be made for the first three days after the injured Employee leaves work unless the period of disability continues for more than 14 days or the Employee is hospitalized as an inpatient for treatment required from the injury. Your Agency may also provide non-state-mandated benefits; contact the Workers’ Compensation Coordinator for information regarding the availability of additional benefits.

 I In accordance with Labor Code Section 4600, a personal physician shall meet all of the following conditions: (A) The physician is the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. (B) The physician is the employee's primary care physician and has previously directed the medical treatment of the employee, and who retains the employee's medical records, including his or her medical history. "Personal physician" includes a medical group, if the medical group is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries. (C) The physician agrees to be pre-designated.

Employees may not be compensated for absences from work due to medical or physical therapy appointments in accordance with the California Labor Code Section 4600 and the Agency’s policy, unless such appointments are requested by the Agency, the TPA, the Administrative Director, the Appeals Board, or a Workers' Compensation judge. Employees may use available accrued leave to cover lost time.

In the event of a work-related injury resulting in death, the Employee’s dependents would be eligible for benefits in accordance with the California Labor Code Section 4700-4709.

For questions regarding compensation, contact Bragg & Associates or the Workers’ Compensation Coordinator.

III. Claim Resolution The State of California guarantees that when medical treatment has brought the injured Employee to the point of maximum medical improvement and if the injury has resulted in permanent disability residuals (permanent restrictions given by the treating physician), the Agency is responsible for making a “permanent disability” payment to the injured Employee through the Third Party Administrator. The amount will be determined based on the percentage of disability and in accordance with the established amounts provided by the California Labor Code laws in compliance with workers’ compensation code. When permanent restrictions are given concerning the injured Employee, the Agency will engage in an interactive process with the injured Employee to determine if it is possible to offer a Modified Usual & Customary assignment or offer a new Alternative assignment to the Employee within the Agency. In accordance with the California Labor Code, a Modified position or Alternative position must provide at least 85% of the wages at the time of injury. If Modified or Alternative work is not available, then the injured Employee may be eligible for vocational rehabilitation benefits (Date of Injury prior to 1/1/04) or Supplemental Job Displacement Benefits (Date of Injury on or after 1/1/04).

CONTACT INFORMATION

NAME/TITLE TELEPHONE Workers’ Compensation Coordinator Third Party Administrator Gregory B. Bragg & Associates (800) 922-5020 Division of Workers’ Compensation Information & Assistance Officer (800) 736-7401

COMMON TERMS USED FOR WORKERS’ COMPENSATION

Date of Injury (DOI): The date that the alleged incident or exposure occurred. The date of injury in cases of occupational diseases or cumulative injuries is that date that the Employee first suffered disability and either knew, or in the exercise of reasonable diligence should have known, that the disability was work-related.

Employee’s Claim for Workers’ Compensation Benefits (DWC Form 1): Division of Workers’ Compensation (DWC) claim form, which is furnished by the Employer and completed by the Employee after an industrial injury.

Employee (EE): The injured Employee.

Employer (ER): The Agency.

Job Description: A description of the required tasks and physical demands of an Employee’s Usual & Customary position. A job description will be given to the Treating Physician for use during the Workers’ Compensation claim.

Transitional Assignment (TA): A temporary assignment provided to an Employee to work during the recovery period of a work-related injury or illness.

Treating Physician (TX): The doctor primarily responsible for managing, monitoring, and reporting about the medical care and treatment of the injured Employee.

Usual & Customary position (U&C): The Employee’s regular job at the time of injury (not necessarily the activities performed while injury occurred).

Medical Only Claims: Claims are considered medical only if the injured Employee has lost no time from work, if the injury is relatively minor, if the claim is not disputed, and if there is no permanent disability. Basically, if the claim only requires medical treatment it becomes a medical only claim.

Indemnity Claims: If a claim involves lost time, is disputed, results in permanent disability or involves subrogation, it becomes an indemnity claim. An indemnity claim is any claim that is not a medical only claim.

Future Medical Claims: Once a claim is settled, if an award of future medical benefits has been approved by the WCAB, the claim remains open to be reviewed periodically by the Third-Party Administrator’s Future Medical Claims Examiner.

Delay/Investigation Process: When an Employee is injured, the claim can be placed on “delay” for several reasons. Usually a claim will be delayed because the employer is disputing the claim, the accident was not witnessed, the injury may not be industrial, an investigation needs to be conducted, etc. A delay letter will be issued within 14 days from the date Bragg & Associates receives the claim.

The Labor Code states a claim can be delayed for no more than ninety days. The employer’s date of knowledge is the first day of the ninety-day period OR if the employer complied with providing a claim form (DWC-1) to the Employee within the first 24 hours of the injury and can prove it, the first day of the ninety-day period is the date the Employee returned the claim form. It is best to use the employer’s date of knowledge to avoid missing a decision due date which is the last day of the ninety day period.

During the ninety-day period, Bragg and Associates will investigate the claim to determine if the injury is industrially related or not. They will conduct any and all necessary investigations, obtain witness statements, obtain prior medical information and possibly have the Employee attend a medical examination to have factual evidence to determine if the claim is industrial. During this period of time, the employer may be requested to cooperate with providing any tools that can help determine if the claim should be accepted or denied.

Per SB899 effective 4/19/04, when a claim is placed on delay the employer/Bragg & Associates is responsible for up to $10,000.00 of medical treatment. The medical treatment will be authorized, if it is reasonable and necessary.

In addition, when the delay letter is sent to an In Pro Per claimant, the claimant will have 10 days to schedule the panel QME and send the forms into the State. If the claimant does not complete the forms within 10 days, Bragg & Associates, Inc. will send the forms into the State and request the panel of QMEs.

If the injured Employee does not comply with the investigation process, the claim may be denied for their failure to cooperate with discovery.

Once a determination has been made, Bragg and Associates will send a claim acceptance letter or denial letter to the Employee and the employer.

To better understand what the Third-Party Claims Administrator does with the workers’ compensation claims, refer to the flowchart of How Claims Are Handled on page 11.

1. Medical: This benefit is provided to cure or relieve the effects of the injury. Treatment will be provided in accordance with the mandated ACOEM guidelines. All medical treatment is subject to utilization review accordingly. If a claim is on delay, medical treatment will be provided according to these guidelines up to a maximum of $10,000.

2. Temporary Total Disability: This benefit is paid to a disabled Employee whose injury temporarily prevents him or her from performing their regular job description duties. The disabled Employee is paid every two weeks until either the maximum medical improvement from the injury has been met or the treating physician has released the Employee to return to work.

3. Permanent Partial Disability: This benefit is paid to a disabled Employee whose injury permanently and adversely affects his or her ability to compete for employment in the open labor market. The percentage rating, from 1.0% to 99.75%, is based on the nature and severity of the injury and the Employee’s age and occupation at the time of injury. The permanent disability rating determines the number of weeks for which this benefit is paid. This benefit is usually paid in a lump sum through a settlement agreement.

4. Life Pension: This benefit is paid to a seriously disabled Employee whose permanent disability rating is between 70% and 99.75%. This benefit is paid every two weeks and depends on the permanent disability rating. This is paid after the last permanent partial disability benefit payment is made and up until the Employee’s death.

5. Vocational Rehabilitation/Supplemental Job Displacement Benefit: This benefit, by statute called a maintenance allowance, is paid to a disabled Employee who cannot return to the job being performed at the time of injury, but qualifies for and accepts vocational rehabilitation services. This benefit may be supplemented with permanent partial disability benefits to draw a maintenance allowance equal to the temporary disability rate. This benefit is paid every two weeks throughout the period during which the Employee receives vocational rehabilitation services, after the last temporary disability benefit payment is made.

6. Death Benefit: This benefit is paid to the dependents of Employees who are fatally injured on the job. This benefit is usually paid to the surviving spouse or dependents monthly. Employers are also liable for “reasonable expenses of the Employee’s burial.”

This Flowchart demonstrates what the Third-Party Adminstrator, Gregory B. Bragg and Associates does with the claims at their office. The State of California requires a liscenced claims administrator to perform these functions. CSRMA has contracted with Gregory B. Bragg and Associates to perform these functions on your behalf.

LOST TIME INCIDENT Call clinic for Authorization New Loss MEDICAL is received ONLY and INCIDENT DELAYED ACCEPTED reviewed DECISION due date is 90 days from to Contact is made if employer (client) date of knowledge of necessary and injury. During this time period, medical determine claim treatment, pursuant to ACOEM guidelines, lost time, Employee is must be authorized up to $10,000 medical contacted, only or Initial letters benefits are delay. explained, initial Delay letter is sent to the injured worker with panel QME letters if in are sent out letters are sent, pro per. The claimant has 10 days to set and notify us of the and medical wage statement is investigation or we will schedule it. The investigation is initiated. This contact is calculated and may consist of obtaining statements, medical records and a medical made. File is benefits begin. evaluation by a State QME. The employer’s help is essential to deny a placed on diary. Various Based on treatments are The claim is accepted or denied by the 90th day. results of Medical authorized subject Decision letter is sent. If accepted, treatment is factual treatment is to ACOEM authorized, etc. information monitored guidelines, until from the according to the Employee is investigation, ACOEM permanent and At anytime the Employee may retain an attorney. All required documents are served on the applicant the claim guidelines stationary or we may be and various dispute an issue. attorney. The applicant attorney will file an Application to obtain a WCAB #. DENIED by treatments the 90th day. are If there is no authorized If the Employee response until does not have an If Employee has attorney: Medical from the Employee is attorney, you will treatment continues until the Employee is Employee discharged settle based on the permanent and stationary. At any time, after the from care. A treating physicians either party can agree or disagree with the claim is 20-day findings, or advise treating physician’s findings. If we disagree denied, the closing letter the injured worker we MUST object and offer AME/QME. If the file is is sent out that we object and applicant attorney does not agree to AME, we CLOSED. and if no disagree with the set QME. response treating physicians We may get additional subrosa etc, to If the from the findings. The deplete Employee's credibility. All reports Employee Employee Employee will go and circumstances of the claim are weighed. objects to the and bills are through the panel Either party can file a DOR and a hearing will denial, they paid, the file QME process with have an is CLOSED. the State. The If you SETTLE the claim through appeal Employee will Compromise and Release, this will process attend the resolve all issues. You negotiate any liens, evaluation wherein pay out all monies due and CLOSE the the report will be IF THE CLAIM DOES NOT claim. sent to the DEU for SETTLE, A TRIAL IS rating. Depending SCHEDULED. Once Trial takes You can also SETTLE by Stipulations with place, you wait approx. 45 days Request for Award leaving the for the Judge (WCJ) to issue his Employee’s future medical open. The file decision. The decision is called remains open and must be reserved for the Findings and Award. This is an

MEDICAL PROVIDER NETWORK: USERS GUIDE

Worker’s Compensation Coordinator Guide

BACKGROUND: We at CSRMA are committed to the well-being and safety of our member’s employees. As part of our commitment, we are implementing a Medical Provider Network (MPN) for job related injuries. Our primary goals are to make sure that every employee who has a work-related injury obtains medical care quickly, is treated appropriately, and safely returns to work as soon as medically possible. The MPN has been chosen because it works effectively for work-related injuries.

As a Worker’s Compensation Coordinator, your role is very important to the success of the MPN program. Please read this information carefully and address any questions you may have to the MPN contact designated below.

CSRMA works with Gregory B. Bragg and Associates and Professional Dynamics to bring the MPN program to our employees. The MPN includes medical providers that specialize in occupational health. Gregory B. Bragg and Associates is our workers’ compensation third party administrator. Professional Dynamics is a national company that provides occupational health, disability management and medical cost management. The MPN will be delivered through Interplan Health’s network of medical providers and facilities.

YOUR MPN CONTACT:

Professional Dynamics Inc, Sheila Drennan MPN Administrator 1-800-591-5501 ext 3 [email protected]

WHEN ANY WORK-RELATED INJURY OR ILLNESS OCCURS: Immediately contact Gregory B. Bragg and Associates to report the injury, file all the required paperwork and forms, and direct the injured employee to the designated MPN provider for an initial medical evaluation and treatment, if appropriate. In your initial implementation packet you should have received notices to post in your place of employment with names of MPN Primary Care medical providers.

You can also access a complete listing of MPN providers on our website: www.professional dynamics.com Access Code 13256 You can also call the Professional Dynamics call center at : 1-800-591-5501 ext 3.

WHEN AN INJURED EMPLOYEE MAY RECEIVE TREATMENT OUTSIDE OF THE MPN FROM A NON-NETWORK PROVIDER/FACILITY: • For treatment of an injury that began prior to the coverage of the MPN for specified conditions. See Attachment I for the Transfer of Ongoing Care Policy; • For emergency care; • When an injured worker has pre-designated their own personal physician; or • When authorized treatment is not available by or through an MPN network provider. (If this situation arises, please refer the employee to the MPN contact above.)

DISTRIBUTION OF EMPLOYEE COMMUNICATIONS: All employees need to receive an MPN Notification Letter when the program is initially rolled out. This letter provides instruction on how employees will access the MPN including changing providers, obtaining second and third opinions and providing continuity of care if a provider is terminated from the MPN. All new covered employees hired after the MPN is implemented should receive a copy of the MPN Notification Letter upon hire.

After an injury is reported Professional Dynamics will send the injured employee another MPN Notification Letter to remind them that their employer is participating in an MPN.

INFORMATION ABOUT THE MPN: There is additional information you must read to familiarize yourself with the MPN program. They include the following: ← • Worker’s Compensation Coordinator Instructions ← • Second and Third Opinion Process ← • Independent Medical Review Process ← • Access Standards ← • Transfer of Ongoing Care Policy ← • Continuity of Care Policy

MEDICAL PROVIDER NETWORK: USERS GUIDE (CONT.)

What To Do If An Employee Is Injured At Work

1. Arrange NON-EMERGENCY CARE: Direct the injured employee to the MPN designated provider for an initial medical evaluation. Notify the injured employee of their right to choose another MPN provider after this initial visit.

Note: The employee has the right to see a doctor close to their home or workplace. Travel must be limited to no more than 15 miles or 30 minutes to see a treating doctor or 30 miles or 60 minutes to see a specialist. In addition, there are alternative access standards set for rural areas.

EMERGENCY CARE: Refer the injured employee to the nearest appropriate MPN medical provider or hospital, or send the employee to the nearest emergency room.

2. Report Once you have learned of an employee’s injury, Gregory B. Bragg and Associates.

3. Communicate Professional Dynamics will send another MPN Notification Letter to the injured worker which will contain information about how injured workers can find providers in their geographical area.

4. Follow-Up If the employee receives initial treatment at a Hospital Emergency Room, contact the employee and ensure that the employee is receiving follow-up care from an MPN medical provider.

MPN Implementation Checklist

1. Verify that the medical providers that your city would like to use are on the MPN provider list. (Provider list can be found at www.professionaldynamics.com Access Code 13256 Additional providers can be added after they are screened and approved by Professional Dynamics and G.B. Bragg and Associates. )

2. Notify Claims Examiner at Bragg and Associates of the date you would like to start using the MPN.

3. Distribute MPN Notification Letter to all employees 30 prior to the desired MPN start date.

Additional Information That May Be Helpful

Second and Third Opinion Process

If the employee disputes either the diagnosis or the treatment that is recommended by the treating physician, the employee has a right to obtain a second and third opinion from physicians within the MPN. During this process, the employee must continue treatment with treating physician(s) within the MPN.

For obtaining a second opinion, it is the employee’s responsibility to:

1. Inform Gregory B. Bragg and Associates they are disputing the treating physician’s opinion and are requesting a second opinion;

2. Select a physician or specialist from a list of available MPN providers; 3. Make an appointment with the second physician within 60 days; and 4. Inform Gregory B. Bragg and Associates Gregory B. Bragg and Associates of the appointment date.

For obtaining a second opinion, it is Gregory B. Bragg and Associates’s responsibility to:

1. Provide a list of MPN providers and/or specialists to the employee for selection of a second opinion physician based on the physician’s specialty or recognized expertise in treating the injury or condition in question; 2. Contact the treating physician; 3. Provide a copy of the medical records or send the necessary medical records to the second opinion physician prior to the appointment; 4. Provide a copy of the records to the employee upon request; and 5. Notify the second opinion physician in writing that he/she has been selected to provide a second opinion and the nature of the dispute.

If the employee does not make an appointment with a second opinion physician within 60 days of receiving the list of available MPN providers, then the employee will not be able to obtain a second opinion regarding the diagnosis or treatment in dispute.

If, after the second opinion physician reviews the employee’s medical records, he/she determines that the injury is outside the scope of his/her practice, the second opinion physician will notify the employee and the employer. Gregory B. Bragg and Associates must provide the employee with a new list of MPN providers.

If the employee disagrees with either the diagnosis or treatment prescribed by the second opinion physician, the employee may seek the opinion of a third physician within the MPN.

For obtaining a third opinion, it is the employee’s responsibility to:

1. Inform Gregory B. Bragg and Associates they are disputing the treating physician’s opinion and are requesting a third opinion;

2. Select a physician or specialist from a list of available MPN providers; 3. Make an appointment with the third physician within 60 days; and 4. Inform Gregory B. Bragg and Associates of the appointment date.

For obtaining a third opinion, it is Gregory B. Bragg and Associate’s responsibility to:

1. Provide a list of MPN providers and/or specialists for the employee to select a third opinion physician based on the physician’s specialty or recognized expertise in treating the injury or condition in question; 2. Contact the treating physician; 3. Provide a copy of the medical records or send the necessary medical records to the third opinion physician prior to the appointment; 4. Provide a copy of the records to the employee upon request; 5. Notify the third opinion physician in writing that he/she has been selected to provide a third opinion and the nature of the dispute; and 6. Provide the employee with a written description of the Independent Medical Review process. See next page for sample letter.

If the employee does not make an appointment with a third opinion physician within 60 days of receiving the list of available MPN providers, then the employee will not be able to obtain a third opinion regarding the diagnosis or treatment in dispute.

If, after the third opinion physician reviews the employee’s medical records, he/she determines that the injury is outside the scope of his/her practice, the third opinion physician will notify the employee and the employer. Gregory B. Bragg and Associates must provide the employee with a new list of MPN providers.

The second and third opinion physicians must provide their opinions of the disputed diagnosis or treatment in writing and offer alternative diagnosis or treatment recommendations, if applicable. These physicians may order diagnostic testing if medically necessary. A copy of the written report must be given to the employee and the employer within 20 days of the date of the appointment or receipt of the results of the diagnostic tests, whichever is later.

If the employee disagrees with either the diagnosis or treatment prescribed by the third opinion physician, the employee may file with the Administrative Director a request for an Independent Medical Review.

Independent Medical Review

The employee must obtain a second and third opinion before he/she can request an Independent Medical Review. If the employee disagrees with either the diagnosis or treatment prescribed by the third opinion physician, the employee may file with the Administrative Director a request for an Independent Medical Review.

The employee may obtain an Independent Medical Review by submitting an application to the

Administrative Director. Gregory B. Bragg and Associates must provide an application form upon request. The Administrative Director or an independent medical review organization will assign the independent medical reviewer.

Gregory B. Bragg and Associates must provide the independent medical reviewer with all information that was considered in regards to the disputed treatment or diagnostic service, including a copy of the following: 1. All correspondence from, and received by, any treating physician who provided the employee with treatment or diagnostic service; and 2. All medical records and other information used by the physicians in making a decision regarding the disputed treatment or diagnostic service.

The independent medical reviewer must conduct a physical examination. It is the employee’s right to schedule when the examination is to take place.

The independent medical reviewer must issue a report to the Administrative Director, in writing, that includes his/her analysis and determination whether the disputed health care service met the state’s treatment guidelines. The report must be issued within 30 days of the examination, or within less time upon request of the Administrative Director. However, if the reviewer certifies the disputed health care service is a serious threat to the employee’s health, the report must be provided within three days of the examination.

If the independent medical reviewer determines the disputed treatment or diagnostic service meets the state’s treatment guidelines, the employee may seek the disputed treatment or diagnostic service from a physician of his/her choice from within or outside the MPN. The employer must pay for the cost of any approved medical treatment.

Access Standards

1. A covered employee will have a residence or workplace within 30 minutes or 15 miles of 0 (i) an MPN primary care physician and (ii) a hospital for emergency care, or if separate from such hospital, a provider of all emergency health care services. 2. A covered employee will have a residence or workplace within 60 minutes or 30 miles of other occupational health services and specialists. 3. The accessibility standards set forth in number (1) and/or (2) above would be considered unreasonably restrictive in rural areas or areas in which health facilities are located at least 30 miles apart. The MPN has established alternative standards for providing medical treatment to injured covered employees in such areas. The alternative standards provide that all services will be available and accessible at reasonable times to all covered employees with a residence or workplace within 60 miles of an MPN primary care physician and within 100 miles of a hospital and other occupational health services and specialists. 4. The following is the MPN’s written policy for arranging or approving medical care if an employee is working or traveling for work or requires treatment outside of the service area when the need for medical care arises:

When an employee has a work-related non-emergent injury or illness outside of the service area, the employee should notify the employer and seek treatment at the

closest occupational health or primary care clinic to the patient.

In the event of an emergency or if urgent care is needed, the employee should seek medical attention from the nearest hospital or urgent care center. If feasible, the employee or a personal representative should report his/her injury/illness within 24 hours of receiving treatment.

Once the injured/ill employee returns to the service area, medical care will be transferred to a provider within the MPN. This information will be communicated through the Employee Handbook.

5. The following is the MPN’s written policy to allow an injured employee to receive emergency medical treatment from a medical service or hospital provider who is not a member of the MPN:

If an employee requires emergency health care services for a work-related injury or illness from a provider who is outside of the MPN, the initial treatment will be covered and the employee, once stabilized will have medical treatment transferred to a provider within the MPN.

“Emergency health care services” means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient’s health in serious jeopardy.

Attachment I to Worker’s Compensation Coordinator Guide

Medical Provider Network (MPN) Continuity of Care Policy

Policy: Gregory B. Bragg and Associates will provide to all employees entering the workers’ compensation system notice of its written continuity of care policy and information regarding the process for an employee to request a review under the policy and will provide, upon request, a copy of the written policy to an employee.

Procedure: 1. Completion of treatment by a terminated provider. Gregory B. Bragg and Associates will, at the request of an injured employee, provide the completion of treatment as set forth in this exhibit by a terminated provider.

a.) The completion of treatment will be provided by a terminated provider to an injured employee who, at the time of the contract’s termination, was receiving services from that provider for one of the conditions described in paragraph b.) 1. below.

b.) Gregory B. Bragg and Associates will provide for the completion of treatment for the following conditions subject to coverage through the workers’ compensation system:

1. An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of treatment will be provided for the duration of the acute condition. If an acute condition turns into a serious chronic condition as defined below in item 2, then the provisions of that section will apply to any transfer of care issue. 2. A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment will be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the Applicant in consultation with the injured employee and the terminated provider and consistent with good professional practice. Completion of treatment under this paragraph will not exceed 12 months from the contract termination date. 3. A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or 0 less. Completion of treatment will be provided for the duration of a terminal illness. 4. Surgery or other procedure. Performance of surgery or other procedure that is authorized by Gregory B. Bragg and Associates as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contract's termination date. If 180 days elapses and the surgery or other procedure has not been completed, then treatment will be provided for a period of time necessary to complete a course of treatment

approved by Gregory B. Bragg and Associates and to arrange for transfer to another provider within the MPN, as determined by Gregory B. Bragg and Associates .

1. Selection of Physician. Gregory B. Bragg and Associates will administer the choice of physician process for Transfer of Care cases pursuant to Labor Code 4616.3. Gregory B. Bragg and Associates will notify the employee of his or her right to be treated by a physician of his or her choice after the first visit from the medical provider network and the method by which the list of participating MPN providers may be accessed by the employee. Selection by the injured employee of a treating physician and any subsequent physicians shall be based on the physician’s specialty or recognized expertise in treating the particular injury or condition in question. 2. Contractual terms and conditions. Gregory B. Bragg and Associates may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, then . Gregory B. Bragg and Associates is not required to continue the provider’s services beyond the contract termination date. 3. Compensation. Unless otherwise agreed by the terminated provider and Gregory B. Bragg and Associates , the services rendered pursuant to this section will be compensated at rates and methods of payment similar to those used by Gregory B. Bragg and Associates for currently contracting providers providing similar services who are practicing in the same or a similar geographic area as the terminated provider. Gregory B. Bragg and Associates is not required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph. 5. Termination for medical disciplinary cause or reason. This Continuity of Care policy will not require Gregory B. Bragg and Associates to provide for completion of treatment by a provider whose contract with CSRMA’s MPN network has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity. 6. Continuity of care beyond requirements. Nothing in this exhibit will preclude Gregory B. Bragg and Associates from providing continuity of care beyond the requirements of this exhibit. 7. Arrangement for treatment. Completion of treatment will be arranged for and monitored as follows:

a.) Selection of Physician Gregory B. Bragg and Associates will administer the choice of physician process for Transfer of Care cases pursuant to Labor Code 4616.3. Gregory B. Bragg and Associates will notify the employee of his or her right to be treated by a physician of his or her choice after the first visit from the medical provider network and the method by which the list of participating providers may be accessed by the employee. Selection by the injured employee of a treating physician and any subsequent physicians shall be based on the physician’s specialty or recognized expertise in treating the particular injury or condition in question.

b.) Case Management All injury claims will be evaluated to determine injury severity and medical condition as set for in Title 8, California Code of Regulations, sections 9767.1 et seq. Gregory B. Bragg and Associates will provide for the completion of treatment for the conditions described in Section 1.b.) of this policy subject to coverage through the workers’ compensation system as follows:

1. Gregory B. Bragg and Associates will require that provider be compliant with the “Terms and Conditions” section of the provider MPN contract. If providers indicate a non- willingness to comply with contractual obligations of the MPN contract, at the onset of care or at any point during care, then Gregory B. Bragg and Associates reserves the right to immediately arrange for transfer of care to an MPN provider. Gregory B. Bragg and Associates also reserves the right to negotiate a treatment plan and cost with the terminated provider. 2. In cases where care needs to be transferred to a new provider, the claims department will work with the terminated provider to develop a mutually agreed upon transfer of care plan. Care will be transferred only when safe to do so. 3. The claims department will monitor ongoing care and work with the medical providers to meet transfer of care plan objectives.

Attachment II

Medical Provider Network (MPN)

Transfer of Ongoing Care Policy

Policy: Gregory B. Bragg and Associates will provide for the completion of treatment for injured covered employees who are being treated outside of the Medical Provider Network (MPN) for an occupational injury or illness that occurred prior to the coverage of the MPN.

Procedure: 1. Completion of treatment inside the MPN. If an injured covered employee is being treated for an occupational injury or illness by a physician or provider prior to coverage of an MPN, and the employee’s physician or provider becomes a provider within the MPN that applies to the injured employee, Gregory B. Bragg and Associates will inform the employee that his/her treatment is being provided by his/her physician or provider under the provisions of the MPN.

2. Completion of treatment outside of the MPN. Injured covered employees who are being treated outside of the MPN for an occupational injury or illness that occurred prior to the coverage of the MPN, including injured covered employees who pre-designated a physician and do not fall within the Labor Code section 4600(d), will continue to be treated outside the MPN for the following conditions: .1a. Acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a duration of not more than 30 days. Completion of treatment will be provided for the duration of the acute condition. If an acute condition turns into a serious chronic condition as defined below in item b., then the provisions of that section will apply to any transfer of care issue. .2b. Serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, catastrophic injury, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over 120 days and requires ongoing treatment to maintain remission or prevent deterioration. Treatment will be provided for a period of time necessary to complete a course of treatment approved by Gregory B. Bragg and Associates and to arrange for transfer to another provider within the MPN, as determined by Gregory B. Bragg and Associates . .3c. Terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of treatment will be provided for the duration of a terminal illness. .4d. Surgery or other procedure. Performance of a surgery or other procedure that is authorized by Gregory B. Bragg and Associates as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days from the MPN coverage effective date. If 180 days elapses and the surgery or other procedure has not been completed, then treatment will be provided for a period of time necessary to complete a course of treatment approved by Gregory B. Bragg and Associates and to arrange for transfer to another provider within the MPN, as determined by Gregory B. Bragg and Associates .

1. Choice of Physician. Gregory B. Bragg and Associates will administer the choice of physician process for Transfer of Care cases pursuant to Labor Code 4616.3. Gregory B. Bragg and Associates will notify the employee of his or her right to be treated by a physician of his or her choice after the first visit from the medical provider network and the method by which the list of participating MPN providers may be accessed by the employee. Selection by the injured employee of a treating physician and any subsequent physicians shall be based on the physician’s specialty or recognized expertise in treating the particular injury or condition in question. 2. Transfer into MPN. If the injured covered employee’s injury or illness does not meet the conditions set forth in (2)(a) through (2)(d) above, Gregory B. Bragg and Associates may transfer the injured covered employee into the MPN for medical treatment. (Comment to match above) 3. Identification of Cases for Transfer of Care. Gregory B. Bragg and Associates claims examiners will evaluate all pending cases as they come up for review after the implementation of the MPN. Injuries will be evaluated to determine where they fit within the criteria set forth in (2) (a) through (2)(d) above. Cases that qualify for transfer of care into the MPN will be reviewed to determine if transfer is feasible based on nature of injury, severity of the injury and anticipated length of treatment. 0 6. Notification to the covered employee. If Gregory B. Bragg and Associates makes a determination regarding the injured covered employee’s medical condition, that necessitates the initiation of the transfer of care process, Gregory B. Bragg and Associates will notify the covered employee at the employee’s residence and a copy of the letter will be sent to the covered employee’s primary treating physician. The notification will be written in English and any other languages requested by the employer. 4. 7. Injured covered employee disputes. If the injured covered employee disputes the medical determination, he/she must request a report from the covered employee’s primary treating physician that addresses whether the covered employee falls within any of the conditions set forth in (2)(a) through (2)(d) above. Disputes concerning the medical determination made by the treating physician concerning the transfer of care will be resolved pursuant to Labor Code section 4062.

.1a. If the treating physician agrees with Gregory B. Bragg and Associates ’s determination that the employee’s medical condition does not meet the stated conditions, the transfer of care will go forward during the dispute resolution process. .2b. If the treating physician disagrees with Gregory B. Bragg and Associates ’s determination that the employee’s medical condition does not meet the stated conditions, the transfer of care will not go forward until the dispute is resolved.

8. Referrals. Referrals made to providers after the inception of the MPN will be made to a provider within the MPN 9. Treatment outside MPN. Gregory B. Bragg and Associates may agree to provide medical care with providers outside of the MPN if such treatment is feasible based on nature of injury, severity of the injury and anticipated length of treatment.

COMMON ABBREVIATIONS

WHO AA Applicant Attorney DA Defense Attorney EE Employee ER Employer DA District Attorney

GENERAL DOI Date of Injury AWW Average Weekly Wage DEU Disability Evaluation Unit DWC-1 Employee Claim Form 5020 Employer’s Report of Occupational Injury or Illness 5021 Doctor’s First Report of Injury AOE/COE Arising out of employment/in the course of employment DOB Date of Birth MOD DUTY The injured Employee is released to work with physical/mental restrictions NLT No lost time RTW Return to Work Three-point contact At the onset of a new loss, Bragg & Associates will contact the employer, injured Employee and the doctor

MEDICAL TERMS ACOEM American College of Occupational and Environmental Medicine AME Agreed Medical Examiner (applicant and defense agree to use one doctor) AQME The applicant’s choice of Qualified Medical Examiner DQME Defendant’s choice of medical evaluation once they have objected DX Diagnosis FOV First office visit HX Medical history LOV Last office visit MMI Maximum medical improvement. The recovery of an injury has stabilized and recovery is maximized. The claim is poised for a permanent disability rating. Same as permanent and stationary N OV Next office visit OBJECT Examiner objects to medical treatment and offers AME/QME or Panel QME P & S Permanent and stationary QME When claimant is not represented by an attorney and either party objects, the claimant goes through a State Panel Qualified Medical Evaluation SX Surgery PTP Treating physician UR Utilization Review DC Chiropractor PT Physical Therapy TREATER Treating Physician

LEGAL TERMS APP The legal filing that initiates litigation in the Workers’ Compensation system C & R Compromise and Release DOR Declaration of Readiness to Proceed (This assigns a court date) 132(a) Labor Code section that allows Employees to petition for penalties against the employer for discriminating against an Employee because they had a workers’ compensation injury. In Pro Per Claimant is not represented by an attorney F & A Findings and Award F & S File and serve the document on the parties MSC Mandatory Settlement Conference L.C. Labor Code PTC Pre Trial Conference S & A Stipulations with Request for Award S & W Serious and Willful Misconduct. Penalty claims filed as a result of injury from willful violations of enforced safety policy. Employer knew of negligence on premises or faulty property, did not fix it and the Employee sues for this in workers compensation arena SUBRO Subrogation (third party recovery) WCAB Workers Compensation Appeals Board WCJ Workers Compensation Judge

INVESTIGATION SUBROSA Obtaining investigation film on a person

BENEFIT TERMS PPD Permanent partial disability (we usually say PD) PTD Permanent total disability (100%) TTD Temporarily total disability (we usually say TD) TPD Temporarily partial disability (modified duty or wage loss) LP Life pension

VOCATIONAL REHABILITATION Voc Rehab or VRVocational Rehabilitation QIW Qualified Injured Worker (for vocational rehabilitation) VRMA Vocational rehabilitation maintenance allowance MOD ALT The injured Employee is QIW and the employer offers permanent modified duty SJDB Supplemental job displacement benefits. Vocational rehabilitation benefit

Remember: Exacerbation A temporary increase of a pre-existing symptom. (Not a new injury) Aggravation An injury whose symptoms have been made worse and/or the symptoms have increased dramatically. (A new injury to be reported, if not first aid)

90-Day Rule: If the employer/insurer fails to reject a claim within 90 days after the claim form is filed, the injury is presumed to be compensable. The employer shall authorize treatment for the alleged injury until the date the claim is accepted or rejected. Liability for medical treatment prior to claim acceptance or rejection shall be limited to ten thousand dollars ($10,000). [LC§5402]

Agreed Medical Evaluator (AME): A medical examiner selected by agreement between the employer and a represented Employee to resolve disputed medical issues referred by the parties in a workers’ compensation proceeding. The report of an AME is considered the evidence of both parties.

Alternative Job: An alternative job is a position that is compatible with an injured Employee’s work restrictions and has different essential functions/tasks than that of the Employee’s Usual & Customary position. This position may currently exist within the company, or it may be created in order to accommodate the work restrictions of the injured Employee. An alternative job for a permanently disabled Employee must meet the following criteria: 1) The Employee must be able to perform the essential functions of job, 2) The job must be a regular position lasting at least 12 months, 3) The wages offered must be at least 85% of wages paid at time of injury, 4) The job must be within a reasonable commuting distance.

AOE (Arising Out of Employment): This is one of the legal tests that must be met for a medical condition to be covered by Workers’ Compensation. An injury arises out of the employment when the nature of the activity resulting in the injury is work related. (See COE)

Applicant: An injured Employee who is represented by an attorney.

Apportionment: The process of determining if some portion of an injured Employee’s disability is due to a cause other than the current injury. Apportionment only applies to Permanent Disability.

Average Weekly Wage (AWW): Used to determine temporary disability benefits payable to an Employee.

Claim: A request for compensation for an injury arising out of and in the course of employment, whether disputed or not, or notice or knowledge that such an injury has occurred or is alleged to have occurred.

Claims Administrator: Employee of an insurance company or third party administrator who oversees the processing of individual Workers’ Compensation claims. Also referred to as Claims Examiner or Claims Adjuster.

COE (occurring in the Course Of Employment): A compensable injury must occur during the course of employment. The activity the Employee was engaged in at the time of injury must grow out of, or be incidental to, his/her employment. (See AOE)

Compensable Injury: An injury sustained by an Employee arising out of (AOE) and occurring in the course of (COE) employment. This includes any aggravation or acceleration, due to employment, of a pre-existing condition.

Cumulative Trauma (CT): An injury caused by repetitive physically or mentally traumatic activities over a period of time, for example carpal tunnel syndrome. The date of injury in a CT claim is non-specific and may involve multiple employers and insurers over time. (See Date of Injury)

Delay: Used by the insurance carrier or third party administrator when it requires additional information to determine if benefits are due. The insurer has 14 days from the date that the employer had knowledge of the claim to issue a delay letter. The employer is responsible for authorizing treatment for the alleged injury until the date that the claim is accepted or rejected; however, liability is limited to $10,000 unless the claim is accepted.

Date of Injury (DOI): The date that the alleged incident or exposure occurred. The date of injury in cases of occupational diseases or cumulative injuries is that date that the Employee first suffered disability and either knew, or in the exercise of reasonable diligence should have known, that the disability was work-related. [LC§ 5411-5412]

DWC Form 1 "Employee’s Claim for Workers’ Compensation Benefits": Division of Workers’ Compensation (DWC) claim form, which is furnished by the employer and completed by the Employee after an industrial injury.

Employer’s Report of Occupational Injury or Illness (5020): A report filed with the insurance carrier or third party administrator by the employer within 5 days of the date of injury detailing the injury as well as pertinent information about the Employee and employer such as name, address, etc.

Investigation: The process of examining and evaluating a claim to determine the nature and extent of all legally required benefits, if any, which are due under the claim. Investigation may include formal and informal methods of gathering information relevant to evaluating the claim such as: obtaining employment records; obtaining earning records; informal or formal interviews of the Employee, employer, or witnesses; deposition of parties or witnesses; obtaining expert opinion where an issue requires an expert opinion for its resolution, etc.

Lien: A charge or obligation imposed upon a specific compensation claim as security for the performance of services related to that claim.

Medical-legal Expense: Costs incurred by or on behalf of any party for tests, reports, records, testimony, etc. for the purpose of approving or disapproving a contested claim.

Modified Job:

© 2004 Lynch & Associates/ Revision 5/2007 Page 28 CSRMA: Workers’ Compensation Management Program Reference Guide The regular position held by the injured Employee prior to the injury, but with a variation of work assignments or limitation in physical job requirements. The Usual & Customary position can be modified for temporary accommodation of work restrictions, or as a permanent offer to a Permanently Disabled injured Employee. Possible job modifications may be limited number of hours worked, lighter physical requirements, or an equipment accommodation. A modified job for a permanently disabled Employee must meet the following criteria: 1) The Employee must be able to perform the essential functions of the job, 2) The job must be a regular position lasting at least 12 months, 3) The wages offered must be at least 85% of wages paid at time of injury, 4) The job must be within a reasonable commuting distance.

Notice of Offer of Modified or Alternative Work: The employer uses the form Notice of Offer of Modified or Alternative Work to offer a modified or alternative position to an injured Employee whose permanent disability precludes him/her from the usual & customary position. The Employee has 30 days to accept or reject the offer. If the Employee does not respond, the offer is presumed to be rejected unless the time period is extended or another agreement is outlined in a collective bargaining agreement.

Objective Factors of Disability: Factors of disability that can be objectively measured, observed or demonstrated. They include physical findings such as range of motion, strength, findings on x-rays, and diagnostic or laboratory test results.

Permanent & Stationary (P&S): As determined by the treating physician, the Employee’s physical condition is considered Permanent & Stationary after it has medically stabilized and is not expected to deteriorate or improve significantly. This is a prerequisite to determining any permanent disability.

Permanent Disability (PD): Residual mental or physical impairment remaining after an injured Employee’s condition is considered Permanent & Stationary. Permanent Disability is rated to determine the percentage of total disability. Permanent Disability payments may be increased by 15% if the employer does not offer a Modified/Alternative Position, or they may be decreased by 15% if the employer does offer a Modified/Alternative Position.

Pre-designated Physician: The personal physician whom the Employee has selected as his/her physician of choice by notifying the employer in writing prior to the date of injury. The physician must agree to this designation for it to be effective. In accordance with Labor Code Section 4600, a personal physician shall meet all of the following conditions: (A) The physician is the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. (B) The physician is the employee's primary care physician and has previously directed the medical treatment of the employee, and who retains the employee's medical records, including his or her medical history. "Personal physician" includes a medical group, if the medical group is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multi-specialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries. (C) The physician agrees to be pre-designated.

Qualified Medical Evaluator (QME): A physician who has been specifically appointed and certified to conduct medical-legal evaluations of injured Employees.

Return to Work (RTW): The commitment to attempt to keep the injured Employee at work during the recovery period or to return him/her to work as soon as possible.

RU-90 Form “Treating Physician’s Report of Disability Status”: © 2004 Lynch & Associates/ Revision 5/2007 Page 29 CSRMA: Workers’ Compensation Management Program Reference Guide (Not applicable for claims with dates of injury on or after 1-1-04) This form was designed by the Division of Workers’ Compensation in 1990 to encourage and facilitate reporting by treating physicians to the insurance carriers or third party administrator. The form is used to report on the Employee’s medical status and indicates whether or not the Employee can return to the pre-injury/Usual & Customary position. If the Employee cannot return to pre-injury status, the treating physician can indicate on the RU-90 when the release is expected or that the Employee is not expected to ever return to the Usual & Customary position. According to the California Code of Regulations §10124 (b), the employer’s insurance carrier or third party administrator is required to contact the treating physician at least every 60 days to complete an RU-90 form.

RU-91 Form “Description of Employee’s Job Duties”: (Not applicable for claims with dates of injury on or after 1-1-04) A check-off description of the physical demands of an Employee’s job. According to the California Code of Regulations §10124 (b), a job description is required when an injured Employee is unable to perform his/her Usual & Customary position for 90 days. The RU-91 form fulfills the state requirements of a job description.

Subjective Factors of Disability: Factors that cannot be objectively measured and are obtained from the injured Employee’s description of symptoms. This includes pain and emotional symptoms.

Subrogation (Subro): When the employer becomes liable for Workers’ Compensation benefits as a result of the negligence of a third party, the employer/insurance company/third party administrator has the right of recovery, or subrogation, against the negligent third party.

Sub Rosa: A term used for undercover investigation of an Employee’s activities to determine the extent of injury. Usually refers to filming/videotaping an Employee without the Employee’s knowledge.

Supplemental Job Displacement Benefit: Applicable for claims with dates of injury on or after 1/1/04. An educational retraining or skills enhancement allowance for injured Employees whose employers are unable to provide work for a permanently disabled Employee consistent with the requirements of Labor Code § 4658.6.

Third Party Administrator (TPA): A company that provides administrative services to self-insured employers. The TPA administers the benefits that the employer has the financial responsibility for paying.

Transitional Assignment: A tool for assisting the Employee to return to their Usual & Customary position. The Transitional Assignment acts as a treatment to improve the Employee’s work tolerance, while keeping him/her in the work environment where expectations for basic Employee behavior, such as attendance and dress code, are in keeping with normal workplace standards.

Total Temporary Disability (TTD): Payments made to an Employee for lost wages if the Employee’s condition is not yet Permanent & Stationary, but does prevent the Employee from performing Usual & Customary position or a Transitional Assignment. TTD payments are calculated at approximately two-thirds of the injured Employee’s Average Weekly Wage up to the State mandated maximum.

Treating Physician: The doctor primarily responsible for managing, monitoring, and reporting about the medical care and treatment of the injured Employee. Also referred to as Treater or PTP (primary treating physician). © 2004 Lynch & Associates/ Revision 5/2007 Page 30 CSRMA: Workers’ Compensation Management Program Reference Guide

Usual & Customary position: The Employee’s regular job at the time of injury (not necessarily the activities performed while injury occurred).

Work Restrictions: Restrictions of specific activities, body positions, motions, exposure, and/or work hours that are placed on the injured Employee by the treating physician temporarily to facilitate recovery, or on a permanent basis due to the effects of the injury.

132 A: A claim for penalty against the employer for discrimination after an injury. Usually not insurable. “Any employer who discharges, or threatens to discharge, or in any manner discriminates against any Employee because he or she has filed or made known his or her intention to file a claim for compensation with his or her employer or an application for adjudication, or because the Employee has received a rating, award, or settlement, is guilty of a misdemeanor and the Employee's compensation shall be increased by one-half, but in no event more than ten thousand dollars ($10,000), together with costs and expenses not in excess of two hundred fifty dollars ($250). Any such Employee shall also be entitled to reinstatement and reimbursement for lost wages and work benefits caused by the acts of the employer.” [LC§132 (a)]

California Labor Code Section 5401(a): First aid is defined as “any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and follow-up visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel.”

Non-recordable The following are generally considered first-aid treatment and need not be recorded if the work-related injury does not involve loss of consciousness, restriction of work or motion, or transfer to another job.  Application of antiseptics during first visit to medical personnel.  Treatment of first-degree burn(s).  Application of bandage(s) during first visit to medical personnel.  Use of elastic bandage(s) during first visit to medical personnel.  Removal of foreign bodies not embedded in eye, if only irrigation is required.  Removal of foreign bodies from wound, if procedure is uncomplicated, and is performed using tweezers or other simple techniques.  Use of non-prescription medicine.  Soaking therapy on initial visit to medical personnel or removal of bandages by soaking.  Application of hot or cold compress(es) during first visit to medical personnel.  Application of ointments to abrasions to prevent drying or cracking.  Application of heat therapy during first visit to medical personnel.  Use of whirlpool bath therapy during first visit to medical personnel.  Negative x-ray results.  Brief observation of injury during first visit to medical personnel.

Note: The administration of a tetanus shot or booster, by itself, is not considered medical treatment. However, injuries requiring tetanus shots may be recordable for other reasons. Injuries or illnesses that are not work-related are not recordable for CAL/OSHA.

Examples of Major Injuries/Illnesses (OSHA Recordable):

 Chest pain  Difficulty breathing  Loss of, or change in, level of consciousness  Severe burns  Head or neck injury  Penetrating wound of chest or abdomen  Amputation  Allergic reaction with tightness in throat, difficulty breathing, or dizziness  Severe bleeding  Obvious fracture with deformity  Falls of greater than 4 feet  Penetrating eye injuries  Toxic chemical exposures (swallowing, inhalation, skin contact); send MSDS  Multiple injuries  Psychiatric disturbances (hallucinations, delusions)  Seizure  Lacerations (cuts) exceeding 2 inches in length  Any injury that results in lost time or restricted duty  Death

If the injured Employee is unable to return to the Usual & Customary position due to permanent restrictions set by the Treating Physician, an alternative or modified job may be offered. The employer and the injured Employee must engage in an interactive process to determine if such an offer is available (see Expanded Definition: California’s Fair Employment and Housing Act).

The offer is made by the Employer through the Insurance Carrier/Third Party Administrator and must meet the following criteria:

 The physical limitations must be within the Treating Physician’s recommendations.

 The job must be a regular position lasting at least 12 consecutive months.

 The position must provide at least 85% of the wages at time of injury. (Minimum wage must be met in accordance with the law.)

 The job must be within a reasonable commute distance.

If an injured Employee either accepts an offer of a Modified or Alternative job or rejects the offer for any reason other than those listed above, then the Employee will not be entitled to supplemental job displacement benefits. For injuries after 1/1/04, the Employee’s permanent disability settlement can be decreased by 15% if the employer offers a Modified or Alternative position, or increased by 15% if the employer does not.

The form Notice of Offer of Modified or Alternative Work is used to make the offer. The injured Employee has 30 days to accept or reject the offer. If the offer is not accepted or rejected within 30 days, the offer is then considered to be rejected by the injured Employee.

What is a permanent disability? A permanent disability occurs when an industrial injury causes or contributes to a significant limitation in performing work.

What is a permanent impairment? The process for determining permanent disability changed as a result of legislative changes that took place in 2004. As a result, the terminology changed from permanent disability to permanent impairment. You will see these terms used interchangeably and they mean essentially the same thing.

What is a permanent disability rating? A permanent disability rating is a figure indicating the percentage of disability based on the nature of the physical injury or disfigurement, the occupation of the injured Employee, and the Employee’s age at the time of injury, with consideration given to the Employee’s diminished future earning capacity. (LC 4660)

Who is entitled to a permanent disability/impairment rating? An injured Employee is entitled to a permanent disability rating if they have incurred a work-related injury that results in a permanent disability that causes a significant handicap in performing work. Employees who are permanently disabled will receive a disability rating.

Why compensate for permanent disability/impairment? “The framers of California Workers’ Compensation law recognized that it is not always enough to provide treatment and temporary compensation. Often an injured Employee will need additional assistance in adjusting to working requirements if any permanent physical or mental impairment has resulted from the injury."(CA Workers’ Compensation Handbook, 6-1)

Do permanent disability payments continue if the injured Employee accepts a job elsewhere? Yes.

What if an injured Employee is TOTALLY permanently disabled? In the event of total permanent disability, indemnity payments based on average weekly earnings are paid for the remainder of the injured Employee’s life.

The term Qualified Injured Worker refers to an injured Employee who has both “medical eligibility” and “vocational feasibility,” and a Date of Injury prior to 1/1/04.

Who is medically eligible? An Employee is medically eligible if the expected permanent disability resulting from his or her injury, whether or not combined with the effects of a prior injury or disability, permanently precludes or is likely to preclude the Employee from engaging in his or her usual occupation at the time of injury. [LC§ 4635]

What determines vocational feasibility? An Employee’s “vocational feasibility” is based on a determination that the Employee can reasonably be expected to return to suitable gainful employment or self-employment through the provision of vocational rehabilitation services.

Who determines QIW status? The Treating Physician makes the determination regarding the likelihood of a full recovery. An Employee is a Qualified Injured Worker once the Treating Physician indicates that the Employee will not, or is not likely to, return to his/her Usual & Customary position, but is able to perform some form of suitable gainful employment. An Agreed Medical Examiner or a Qualified Medical Examiner may be requested to make a determination of QIW. The only three individuals who can make a QIW determination are the Treating Physician, the AME or the QME.

What if the Treating Physician does not seem able or willing to make QIW determination? After 365 aggregate days of total temporary disability from the Usual & Customary position the Employee is presumed to be a Qualified Injured Worker. The Treating Physician can reverse this presumption at any time by indicating that the Employee is physically capable of performing the Usual & Customary position.

Disability Rating The first part of settling a claim is determining the level of permanent disability. Both parties (Employer and Employee) may agree on a permanent disability rating based on the treating physician’s evaluation. If both parties do not agree to this rating, then the Employee’s permanent disability would be determined by a Qualified Medical Evaluator (if the Employee is not represented by an attorney) or by an Agreed Medical Evaluator (if the Employee is represented by an attorney, and both parties agree to an AME).

Settlement Options The next step after permanent disability has been determined is to resolve the claims with a settlement.

The claim is resolved with one of the following three types of settlements. The Workers’ Compensation Appeals Board must approve the settlement before the claim can be closed. The injured Employee’s attorney fees, if any, will be deducted from any settlement amount.

 Stipulation Settling by stipulations (“by stips”) means that a dollar amount is determined based on the percentage of permanent disability, which is then paid out bi-weekly. Future medical treatment remains open indefinitely.

 Compromise and Release A Compromise and Release settlement (C&R) is a lump sum settlement, which is determined based on the percentage of permanent disability plus a lump sum estimate of future medical costs. All issues are resolved with this type of settlement, and the claim is closed after the Workers’ Compensation Appeals Board approves the settlement. Vocational Rehabilitation benefits or Supplemental Job Displacement Benefits can be settled as part of the C&R if the employee is represented by an attorney.

 Findings and Award Findings and Award settlements (F&A) are not as common as the other two types of settlements. If no agreement can be made between the Insurance Carrier/Third Party Administrator and the Applicant Attorney, then all reports and information are submitted for a trial with the Workers’ Compensation Appeals Board judge who then makes a final ruling on the case.

IMPORTANT NOTE: The supplemental job displacement benefit is only an option for injuries that occurred on or after 1/1/04. For injuries that occurred on or before 12/31/03, see the Expanded Definition: Vocational Rehabilitation.

If an injury causes Permanent Partial Disability (PPD) and the injured Employee does not return to work for the Employer within 60 days of the termination of Total Temporary Disability payments, the injured Employee will be eligible for a supplemental job displacement benefit. This benefit is in the form of a nontransferable voucher for education-related retraining or skill enhancement, or both, at state approved or accredited schools The amount of the voucher is determined based on the Employee’s Permanent Partial Disability (PPD) award as follows: PPD Award Voucher Amount less than 15% up to $4,000 15-25% up to $6,000 26-49% up to $8,000 50-99% up to $10,000 The vouchers may be used for payment of tuition, fees, books, and other expenses required by the school for retraining or skill enhancement. No more than 10 percent of the voucher moneys may be used for vocational or return to work counseling.

IMPORTANT NOTE: Vocational Rehabilitation is only an option for injuries that occurred on or before 12/31/03. For injuries occurring on or after 1/1/04, see the Expanded Definition: Supplemental Job Displacement Benefit.

Vocational rehabilitation is the process of identifying and executing a program designed to provide assistance in returning a Qualified Injured Worker (QIW) to the labor market. A vocational rehabilitation plan may involve modified or alternative work, direct job placement, on-the-job training, formal training, academic instruction, job placement assistance, or self-employment. After a QIW accepts vocational rehabilitation, he/she is assigned to a Vocational Rehabilitation Counselor (VRC) who works with the QIW through the following phases:

Initial Evaluation This first phase takes place over one or two sessions and includes an explanation of the vocational rehabilitation benefit, a review of the Employee’s medical file, testing to determine the Employee’s occupational interests, and a discussion of the Employee’s medical situation, interests, work history, education, family and financial situation, and transferable skills.

Vocational Exploration and Planning According to California Labor Code law, the vocational rehabilitation plan should be developed within 90 days. If no plan is developed within 90 days, an Informal Conference is called to identify problems and make recommendations. This typically includes meeting with the Employee to provide vocational counseling, vocational testing, labor market analysis, and vocational research.

Plan Development At this phase the State of California Division of Workers’ Compensation form RU-102 “Vocational Rehabilitation Plan” is completed. The plan can be any one of the following:  Modified or Alternative work: a direct placement with the original employer after the RU-94 offer period has expired. This type of plan typically requires no follow up, and so the case would be closed immediately after Workers’ Compensation Appeals Board approval of the RU-102.  Direct job placement: The maximum time for implementing a direct job placement plan is 90 days.  Formal training/academic instruction: These plans typically range from 90 days to 12 months, with the average being 3-6 months.  Self-employment: These plans typically take 3-6 months to implement.

Throughout the vocational rehabilitation process, the VRC will provide monthly reports to the Insurance Carrier/TPA using the DWC form RU-121. The maximum vocational rehabilitation benefit to a Qualified Injured Worker is $16,000 including all costs. When there is a dispute at any point in the process, either party can file a dispute resolution form (RU-103) to request a Formal Conference.

In lieu of Vocational Rehabilitation services, the California Labor Code allows for a $10,000 settlement for claims with a Date of Injury prior to 1/1/04.

The Americans with Disabilities Act (ADA) makes it unlawful to discriminate in employment against a qualified individual with a disability. U.S. Equal Employment Commission

What employers are covered by the ADA? The ADA Title I employment provisions apply to private employers, State and local governments, employment agencies, and labor unions with 15 or more Employees.

Who is protected by the ADA? Qualified individuals with disabilities are protected by the ADA.

What qualifies an individual as disabled? Under the ADA, a qualified individual has a physical or mental disability that substantially limits a major life activity. • Physical or mental disability: includes all mental and psychological disorders and cosmetic disfigurements. • Substantially limits: a substantial limitation in the ability to work involves restricted ability in respect to a class of jobs or a broad range of jobs in various classes as compared to the average person. • Major life activity: includes hearing, seeing, speaking, walking, learning, or working. It is important to note that in California, the determiners of qualification are somewhat different. See the definition “California’s Fair Employment and Housing Act” for a detailed description of the requirements for qualification in California.

What else is necessary for a disabled individual to be protected from job discrimination under the ADA? First, the individual must meet the employer’s requirements for the job. This includes having the necessary education, skills, licenses and/or work experience. Second, the individual must be able to perform all of the essential functions of the job with or without reasonable accommodation.

What employment practices are covered? All aspects of employment are covered including: recruitment, hiring, placement, training, salary, benefits, promotion, firing, and all other related activities.

What is reasonable accommodation? An accommodation is a change or adjustment which would allow a disabled Employee to perform the essential functions of the job, participate in the application process, and enjoy the benefits and privileges of employment equal to those enjoyed by Employees without disabilities.

An accommodation is considered reasonable unless it: 1. Causes undue hardship. Undue hardship is an action requiring significant difficulty or expense, or 2. Poses a direct threat to the safety or health of the disabled Employee or others, and the disabled Employee cannot perform the job safely with or without reasonable accommodation.

Does an employer have to give preference to a qualified individual with a disability? No. Employers are free to select the most qualified applicant available, and make decisions based on reasons unrelated to a disability.

In September 2000, California’s Fair Employment and Housing Act (FEHA) was amended to significantly broaden the protections afforded to mentally and physically disabled Employees in California. FEHA differentiates California law from the federal Americans with Disabilities Act (ADA), and provides broader coverage for disabled individuals than exists under federal law. FEHA applies to employers with 5 or more Employees.

Assembly Bill 2222, which came into effect on January 1, 2001, clarifies the FEHA’s definition of disabilities and significantly expanded the qualifications for entitlement to protection by the federal Americans with Disabilities Act. AB 2222 also requires employers to engage in an interactive process with Employees seeking a reasonable accommodation on account of a disability.

Definitions Under California law, mental and physical disabilities are defined as those impairments that limit a major life activity; unlike the federal standard that requires substantial limitation. Additionally, under AB 2222, the definition of major life activities is expanded to include working in a particular job. The law also specifies that certain conditions automatically constitute disabilities, for example HIV/AIDS, hepatitis, epilepsy, diabetes, clinical depression and heart disease. In opposition to a 1999 United States Supreme Court ruling, AB 2222 does not take mitigating measures such as medications, assistive devices (like eyeglasses), and prosthetics into consideration when determining whether or not an individual suffers from a protected disability.

Interactive Process According to the FEHA, Employers in California are required to engage in a "timely, good faith, interactive process to determine effective reasonable accommodations" at the request of a disabled Employee. In Johnson v. Wells Fargo Bank, the Court of Appeal reversed a Supreme Court judgment and found that simply notifying the Employee that she was able to apply for open and available positions did not fulfill the obligation to engage in an interactive process. Employers must have an interactive dialogue with the Employee to mutually decide reasonable accommodations. It is important to note that California law requires an interactive process with the Employee regardless of whether or not an appropriate reasonable accommodation exists.

An Employer’s Duty to Provide Reasonable Accommodation California law does not differentiate from the ADA in that an employer is still not required to accommodate an individual when to do so would be an “undue hardship” or if the accommodated individual would pose a “direct threat” to the health or safety of his/herself. See the Definition below of “Defenses Available to the Employer Under ADA/FEHA” for a more detailed assessment of this aspect of the law.

UNDUE HARDSHIP

An employer is not required to accommodate an individual when to do so would be an “undue hardship.” What is considered to be an “undue hardship” is an action requiring significant difficulty or expense to the employer. Consider these factors:

1. What effect does this have on expenses and resources of the employer? 2. How many people are employed by the employer? 3. What type, and at what cost, is the accommodation? 4. Does the employer have the financial resources? 5. What impact does the accommodation have on the operation of the facility, including fellow Employees in their ability to perform their duties, as well as the ability for the employer to conduct business?

DIRECT THREAT

The employer is not required to accommodate an individual who poses a “direct threat” to the health or safety of his/herself or that of others or if the job cannot be performed safely even after the reasonable accommodation. Consider these factors:

• The duration of the risk • The nature and severity of the potential harm • The likelihood harm will occur • The eminence of the potential harm.

The accommodation is considered a “direct threat” if you cannot eliminate or reduce a significant risk of substantial harm for the health and safety of the individual or others.

A determination must be made on a case-by-case basis. The decision cannot be based on speculative threat to the health and safety of the individual or others.

If a determination is made that the individual poses a “direct threat,” it should be based on an individualized assessment of the individual’s present ability to safely perform the essential functions of his/her job. The basis for this assessment should be a reasonable medical judgment that relies on the current medical information.

The Family and Medical Leave Act (FMLA) was enacted in 1993 to allow eligible Employees to take up to 12 weeks of unpaid, job- protected leave each year for specified family and medical reasons. A private employer is covered by FMLA if they employ 50 or more Employees for each working day during each of 20 or more calendar workweeks in the current or preceding calendar year. Public employers are covered regardless of the number of Employees.

Purposes of the FMLA The FMLA allows Employees to balance their work and family life by taking reasonable unpaid leave for certain reasons. The FMLA is intended to balance the demands of the workplace with the needs of families, to promote the stability and economic security of families, and to promote national interests in preserving family integrity.

Eligibility To be eligible for FMLA benefits, an Employee must: 1. Work for a covered Employer; 2. Have worked for the Employer for at least a total of 12 months; 3. Have worked at least 1,250 hours over the prior 12 months; and, 4. Work at a location where the Employer employs at least 50 Employees within 75 miles.

Amount and Type of Leave Eligible Employees are entitled to up to 12 weeks leave during a 12-month period for one the following reasons:  Birth of child, and in order to care for the child*  Placement of child for adoption or foster care *  To provide care for parent, child or spouse with a serious health condition  Employee’s own serious health condition (including those caused by work-related injuries.) Intermittent leave is permitted for serious health conditions when medically necessary.

Computation of 12-month Period The Employer must select one method of computation and apply it to all FMLA leaves within their organization. Multi-state Employers can select one method for an individual state and another method for operations outside of that state. The FMLA provides for the following methods of computation.  The calendar year;  Any fixed 12-month leave year, such as the fiscal year or the year starting on the Employee’s hire date anniversary;  The 12-month period measured forward from the date the Employee’s first leave begins; or  A rolling 12-month period measured backward from the date an Employee uses any FMLA leave. If the Employer does not select a method of computation and notify Employees of the method, then the Employee can select the most advantageous 12-month period.

FMLA and Workers’ Compensation Lost time due to a work-related injury is included in the FMLA 12-week job protection period. In order to exhaust the 12-week period, the Employer must send written notice to the Employee. Until the written notice is sent, none of the days count against the leave.

*Note: The Employer should be sure to refer to the California Family Rights Act for provisions related to pregnancy or childcare leaves of absence.

The Job Accommodation Network (JAN) is a free service of the Office of Disability Employment Policy of the United States Department of Labor. JAN provides information about job accommodations, the Americans with Disabilities Act (ADA), and the employability of people with disabilities. JAN can be found on the Internet at http://www.jan.wvu.edu or by telephone at (800) 526-7234.

Searchable Online Accommodation Resource (SOAR) JAN maintains a searchable list of various accommodation options. Go to this page first (either click on the link from the home page or go directly to http://www.jan.wvu.edu/soar/index.htm) to see if there are appropriate accommodation solutions there. If not, contact JAN directly.

Toll Free Information Service JAN accepts toll-free calls for information about job accommodations and the employability of people with limitations. All calls are confidential. When you call:  A professional consultant will answer your call and ask you for some basic information about the Employee, worksite and job requirements.  The consultant will draw from his/her professional experience and JAN’s files of solutions to identify accommodations for the specific situation. The consultant may also engage other experts as an additional resource.  You will receive accommodation recommendations over the phone, and then follow-up information will be provided by email, fax and/or mail.

JAN’s contact information is as follows:

Accommodations: (800) 526-7234 ADA Information: (800) ADA-WORK (800) 232-9675 Postal: PO Box 6080, WVU, Morgantown, WV 26506-6080 Email: [email protected] World Wide Web: http://www.jan.wvu.edu

Calls are answered 8 a.m. to 5 p.m. Pacific Time Monday through Thursday, and on Fridays from 5 a.m. to 4 p.m. Machines answer after-hours calls. Internet resources are available at all times.

Job Accommodation Network Forums This section of the website is for employers to post either accommodation solutions they have implemented successfully, or to ask for advice from other employers. To reach the forums, either click on the link from the homepage or go directly to http://www.jan.wvu.edu/links/forums.htm.

Much more… The JAN website is full of information about accommodation, ADA and other related issues. Remember when reading the information on this site that it is a national website and does not always address the laws of individual states. Refer to the definition of California’s Fair Employment And Housing Act (FEHA) in this manual for a better understanding of how ADA is addressed in California.

A. How does the workers’ compensation process begin?

The process begins when the employer is made aware of an injury, illness, or death of an Employee that is the result of the Employee’s work.

B. What constitutes notice of a workers’ compensation claim?

A claim is created when an Employee suffers a work-related injury, illness, or death and the employer is notified by one of the following:  Employee tells Supervisor of the incident;  Employee tells another Employee of the incident;  Another Employee observes injury and tells Supervisor of the incident;  Employee’s Supervisor observes an incident;  The Employee’s legal representative files a claim with the employer.

C. Where does the Employee receive medical treatment?

1. In the case of an emergency and/or serious injury or illness, Call 911. 2. In the case of a non-emergency situation the employee should be directed to the Agency’s designated Medical Provider Network (MPN) Facility unless the employee has completed a written request for his/her Personal Physician to treat him/her before the work injury occurs.

D. Can an Employee use his/her own medical doctor for treatment of an injury or illness?

1. The employee can treat with his/her primary treating physician if he/she meets the requirements set forth in the Labor Code and if the employee made his/her request known to the employer to be treated by this doctor in writing to his/her employer before a work injury occurs.

E. When can the Employee return to work?

1. Following the receipt of treatment by the doctor, the doctor should provide the Employee with an Employee Status Report, which will tell the Supervisor if the Employee can return to work and under what conditions. 2. If the Employee Status Report is unclear as to the conditions under which an Employee can return, the Supervisor should call the Claims Examiner for clarification. The Employee should not be returned to work until clarification is received.

F. Does the employer have to take an Employee back for limited duty?

The employer can review the conditions of return to work from the doctor. If the employer can’t accommodate those conditions without further aggravating the injury/illness, the employer does not have to bring the Employee back until work is available that would not aggravate the injury/illness. If a limited duty program is created, it must be offered equally to all workers’ compensation injured Employees in the specific job classification.

G. Who pays for any doctor bill, hospitalization charges, ambulance fees, and/or medication that result from the injury/illness?

© 2005 G. B. Bragg & Associates Page 45 CSRMA: Workers’ Compensation Management Program Reference Guide 1. If the injury/illness is accepted as a legitimate workers’ compensation claim, then the employer, through the claims administrator, pays these expenses for the Employee. 2. If the claim is accepted and the Employee receives a bill for the above services, the Supervisor should obtain the bill and send it to the Claims Examiner for payment.

H. When does an Employee begin to receive his workers’ compensation disability payments?

1. If an Employee is off more than three calendar days due to a workers’ compensation injury/illness, he/she will begin receiving workers’ compensation temporary disability payments. These payments may be supplemented with an Employee’s accrued sick leave and vacation to provide a full paycheck. The supplemental payments are not tax-free. 2. Police officers and firemen receive full pay, tax-free from the first day of disability for up to one year. 3. If an Employee runs out of supplements, he/she will continue to receive the temporary disability payments as long as he/she is off work and eligible for the benefits.

I. Are workers’ compensation injuries always accepted as job related and benefits provided to the Employee?

No. There are three notices that can be sent to an Employee regarding their workers’ compensation claim. The first notice is that the claim is accepted. The second notice states that acceptance or denial is delayed for up to 90 days pending the receipt of more information to determine whether or not the claim is accepted. The third notice states that the claim is rejected as not being work related and no benefits will be provided. If the acceptance of a claim is delayed and later accepted, then all benefits due to the Employee, from the date of injury, will be provided.

J. If I know that the Employee is faking or was injured off the job, what can I do?

If you are aware of the possibility that this is not a work-related injury, contact the Claims Examiner and provide him/her with the information you have. An investigation will be conducted and the claim will be reviewed to see if it is a valid claim.

K. If the Employee is off work, what can I do to get him/her back?

Once a doctor takes an Employee off work for a workers’ compensation injury/illness, it takes a doctor’s statement to bring the Employee back to full or limited duty. You can follow the procedures in this program outlined in the Workers’ Compensation Coordinator Checklist for Return to Work Procedures. You may also contact the CSRMA Return to Work Specialist at [email protected] or 925-922-0305. If you have knowledge that the Employee is doing similar work while off, contact the Claims Examiner and he/she will investigate the matter, including talking to the doctor about returning the Employee to duty.

L. Does the Employee have the right to an attorney in workers’ compensation cases?

Yes. The benefits are very specific in the law; however, some Employees want an attorney to represent them. Once a settlement is reached in the case, the attorney gets a certain percentage of the Employee’s settlement. If you know an Employee has an attorney, you should not discuss the details of the case with the Employee. You can discuss how the Employee is feeling and when the doctor may allow them back to work and/or whether they have future medical appointments.

M. What can I do about follow-up treatment or evaluations for accepted workers’ compensation claims?

The Employee has the right to follow-up treatment or evaluation ordered by a physician. They will be paid mileage to and from the doctor’s office. If the Employee has returned to work and has treatment or an evaluation, you can request that he/she schedule the treatment at the beginning or ending of a shift to reduce disruption to the work site. The Employee will not receive a temporary disability payment for treatment or a follow-up evaluation unless the treatment requires that the Employee miss his/her entire normal work shift.

N. When can I replace an Employee if he/she cannot return to work because of the workers’ compensation injury?

© 2005 G. B. Bragg & Associates Page 46 CSRMA: Workers’ Compensation Management Program Reference Guide 1. Generally, once a doctor has declared the Employee’s condition to be permanent and stationary (P&S) and has defined the conditions of work, which preclude the Employee from returning to work, you can replace the Employee. However, before taking any action, you should check with your personnel department and Bragg & Associates. Also CSRMA directs it’s members to contact the Employment Practices Liability Hotline at: (415)512-3000 or (310) 981-2000.

2. Under recent federal law established through the Americans with Disabilities Act (PL 101-336), an employer is required to try and make “reasonable accommodations” for an injured Employee trying to return to work. Reasonable accommodation should be explored and documented before making a final decision to release/replace an Employee.

O. What are some of the benefits due an Employee who is injured at work?

If the claim is accepted as legitimate, the following are some of the benefits:  The Employee’s injury/illness-related medical bills and transportation will be paid.  If the Employee misses work, he/she will receive tax-free temporary disability payments until the Employee returns to work, appropriate modified duty is offered, is retired, or the case is closed.  If the Employee cannot return to his/her normal job, and a permanent modified duty or alternate position can not be found, the employee will either receive rehabilitation services or supplementary job displacement benefits depending on the date of injury.  The Employee may be eligible for a cash payment for permanent disability if it is found that the Employee has suffered some percentage of permanent disability due to the injury. The amount of the payment is determined by medical statements about the degree of permanent disability by a physician, and the use of a state mandated rating system.  If the Employee dies due to a work-related injury, there are specific burial and death benefits provided to his/her dependents.

P. What are the different types of workers’ compensation injuries?

Specific Injuries: Struck by object, slip & fall, cuts, back strain while lifting, etc.

Cumulative Trauma: Condition caused by repetitive activities developing over time. Example: Carpal Tunnel Syndrome

Aggravation Injuries: A pre-existing condition worsened by some aspect of employment. Prior injury and medical Records are crucial (apportionment). Examples: back, psyche, heart, etc. Exacerbation is same injury. Aggravation is a new injury.

Q. What is a First Aid Injury?

Per California Labor Code Section 5401(a): First aid is defined as “any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care.”

What First Aid Does Not Include:

1. Pesticide Poisoning: Any one-time treatment administered for pesticide poisoning or suspected pesticide poisoning is not included in the definition of first aid. Therefore, all pesticide poisoning claims must be reported irrespective of the level or number of treatments.

2. Hazardous Substances: First aid does not include any one-time treatment by a physician for any serious exposure to a hazardous substance as a result of a specific incident or over time, in a degree or amount sufficient to create a substantial probability that death or serious physical harm in the future could result from the exposure.

3. Loss of Consciousness, Restriction from Work or Motion or Transfer to Another Job: First aid does not include any injuries resulting from loss of consciousness, restriction from work or motion or transfer to another job.

First aid claims do not have a minimum or maximum dollar amount threshold.

R. Why does the Claims Examiner need the Employee’s payroll log or wage statement?

At the time of the injury, the claims administrator must have earnings of the Employee’s “gross” wages for one year BEFORE the injury. This report can usually be generated from the payroll department and faxed when the new loss is reported. This information is required by the WCAB when claimant is not earning maximum disability benefits. A new wage statement will also be needed if an Employee is entitled to disability benefits two years after the date of injury, due to possible increases.