2018 GOSH Conference Presentation Pennsylvania Bureau of Workers

2018 GOSH Conference Presentation Pennsylvania Bureau of Workers’ Compensation • Scott G Weiant, Director Bureau of Workers’ Compensation • Eric Preputnick, Deputy Chief Counsel, Workers’ Compensation • Charece Collins, Chief, Self-Insurance Division • Patricia Clemens, Chief, Health Care Services Division • Harte Pricer, Claims Management Division, Manager of Electronic Data Interchange (EDI)

2018 GOSH Conference Presentation Health & Safety Division Report Processing and Audit Section: • Conduct audits of Self Insured Employers, and Insurance carriers licensed to write WC insurance in PA. • Conduct reviews of workplace safety committees to ensure compliance with regulatory certification mandates. • Maintain oversight for the Accident & Illness Prevention Services Providers Requirements. • Assist with the operation of the Governors’ Award for Safety Excellence Award •

2018 GOSH Conference Presentation Health & Safety Division Certification & Education Section: • Maintain oversight for the daily operation of the Workplace Safety Committee Certification Program • Manage the PA Training for Health and Safety (PATHS) program. • Assist with the operation of the Governors’ Award for Safety Excellence Award •

2018 GOSH Conference Presentation Self-Insurance Division • • • Process and decide applications of individual employers for selfinsurance Set conditions for self-insurance and monitor self-insured employers’ compliance with these conditions for approximately 750 SI employers. Process and decide applications of groups of employers to operate as group self-insurance funds. Regulate and monitor the financial conditions of the group funds including the setting of rates, the maintenance of surplus, and the distribution of dividends to members. 18 group SI funds covering approximately 857 employers in PA. •

2018 GOSH Conference Presentation The Flow of a Workers’ Compensation Claim

2018 GOSH Conference Presentation The Flow of a Workers’ Compensation Claim (Cont’d. )

2018 GOSH Conference Presentation Health Care Services Division Panel Providers – 34 Pa. Code §§ 127. 751 -127. 755 Ø What is the effect of having a provider panel for workers’ compensation? Ø Who develops the provider panel? Ø Why is properly posting a panel so important? Ø Is there anything an employer needs to do besides properly posting the panel? Ø How is having a provider panel different from directing a worker’s care? Ø What happens if an employee isn’t satisfied with the care they are receiving from their panel provider? Ø Are there any times when a worker doesn’t have to use a panel provider? Ø What happens at the end of the 90 day panel provider period? •

2018 GOSH Conference Presentation The Flow of a Workers’ Compensation Claim Litigated

2018 GOSH Conference Presentation The Flow of a Workers’ Compensation Claim Litigated (Cont’d. )

2018 GOSH Conference Presentation Health Care Services Division Medical Fee Review– 34 Pa. Code §§ 127. 251 -127. 261 Ø What medical treatments are covered by Pennsylvania Workers’ Compensation? Ø How are medical bills paid? Ø Can workers be balance billed if the comp reimbursement is lower than the provider’s charge? Ø What happens when a provider isn’t paid correctly or timely? •

2018 GOSH Conference Presentation Health Care Services Division Utilization Review– 34 Pa. Code §§ 127. 401 -127. 556 Ø What is the purpose of a utilization review? Ø Who can file a utilization review (UR)? Ø Who performs the utilization review? Ø Can a worker receive the treatment under review while the UR is pending? Ø What’s the average cost of a utilization review? Ø How long does a utilization review last?

2018 GOSH Conference Presentation Health Care Services Division Independent Medical Exam– Section 314 of the Act Ø What is an Independent Medical Exam (IME)? Ø Who performs IMEs? Ø What happens if an employee doesn’t go to an IME? Ø How often can an IME be performed? •

2018 GOSH Conference Presentation Health Care Services Division Impairment Rating Evaluation– Section 306(a. 2) of the Act Ø What is an Impairment Rating Evaluation (IRE)? Ø What is the difference between total disability and partial disability? Ø Why aren’t IREs currently being performed for PA Workers’ Compensation? •

2018 GOSH Conference Presentation Health Care Services Division Medical Accessibility Study– Section 306(f. 1)(3)(iv) of the Act Ø What is the Medical Accessibility Study? Ø Who performs the Medical Accessibility Study? Ø Where can a copy of the most recently published study be found? •

2018 GOSH Conference Presentation Tips for success: • Communication is key! Communication should occur regularly between you, the claims adjuster, and the claimant. • Register in WCAIS to stay informed of what is going on with the claim, what forms are being filed, and what electronic submissions are being made to update the WCAIS claim status.

2018 GOSH Conference Presentation If you have any questions after this session, you may either call our Helpline at 800 -482 -2383, or if you are a registered user, you may submit claim-related questions via a Customer Service Ticket in WCAIS. If you would like to become registered, the system will walk you through the process or, if you are unsure, our Helpline is available for this as well.

2018 GOSH Conference Presentation