When an employee gets injured on the job, the most important thing is to provide them with prompt and appropriate medical attention. But that’s not the only thing to consider when handling a work injury. It’s important to report any work-related injuries promptly and file a workers’ compensation claim so the injured employee can receive the care they need and get reimbursed for lost wages and medical expenses.
Navigating the workers’ comp claims process can be challenging for employers, since the process can vary from one state and insurance carrier to the next. Here’s what you need to know about workers’ compensation insurance, and how to use automation to simplify the process for your HR team and for injured employees.
What Is the Workers’ Compensation Claims Process?
The workers’ comp claims process includes all of the steps that an employer needs to go through so an injured employee can receive workers’ compensation benefits. These benefits may include lost wages and reimbursement for medical care that the injured worker needs following a workplace injury.
Both the employer and the employee have a role to play in the workers’ compensation process, from filling out claim forms to documenting medical treatment. Depending on the severity of the injury, a workers’ comp case manager may serve as a coordinator between the insurance company, medical providers, and other third parties.
The workers’ comp claims process extends from the first report of injury — a reporting and recordkeeping requirement — all the way to the return-to-work process, when the employee returns to work after getting approval from a medical provider.
Ensuring a smooth and efficient workers’ comp claims process helps you comply with federal and state laws, and support the well-being of injured employees.
6 Steps to the Workers’ Comp Claims Process
The workers’ compensation process may vary slightly depending on the severity of the injury, the nature of the employee’s claim, your insurance coverage, and the guidelines of your state’s workers’ compensation program. For the most part, you can expect the process to involve the following six steps.
1. Provide emergency medical care
It should go without saying, but the first step is to provide appropriate medical attention whenever there’s a workplace accident or personal injury. This could be anything from minor first aid administered on site to a hospital stay or emergency room visit.
In other cases, the employee may develop an occupational disease, such as back pain or carpal tunnel syndrome, related to their job. They may still qualify for workers’ comp, as long as the injury is the result of their employment.
2. Document the injury
Next, create an incident report or ask the employee to provide a written record of their injury. Document the incident as thoroughly as possible, and retain any photo or video evidence, if available. You may need this for a workplace investigation later.
3. File a first report of injury
Now, file a first report of injury with your state’s workers’ compensation board, if you’re required to do so in your state. This step is time-sensitive, with some states requiring the report to be made within 30 days of learning about the injury.
Depending on the severity of the injury, you may also be required to file a report with OSHA, the Occupational Safety and Health Administration. This is especially true for incidents that require hospitalization, which require a report within 24 hours.
4. File a workers’ comp claim
The next step is to file a claim with your insurance carrier. The injured employee should be involved in this part of the process, and may need to submit their own claim form or statement, along with documentation of the injury from their medical provider.
5. Respond to adjuster communications
After receiving the claim, the insurance company will review it and decide whether or not to approve it. If they approve it, the injured employee can accept the offer, which could be a lump sum payment or compensation for lost wages or medical bills.
If the insurance company denies the claim, the employee has the right to appeal it or request a reconsideration from the insurance provider.
6. Navigate the return-to-work process
Finally, it’s time to initiate the return-to-work process and help the employee transition back into their usual role. Depending on the injury, they could be out of work for a few days, or qualify for an extended leave of absence.
Either way, you can request a fitness-for-duty certificate that stipulates when they can return to work, and whether they require any modifications or light-duty assignments. If the employee has a permanent disability as a result of the injury, they may qualify for reasonable accommodation under the Americans with Disabilities Act (ADA).
Best Practices for Workers’ Compensation Claims
Ensuring that your employees have access to workers’ comp benefits isn’t just the right thing to do — it also enables them to return to work faster and with appropriate medical care so they can avoid further injuries and workplace safety incidents. You can make the process easier for everyone involved by following these best practices.
Know your legal obligations
Each state has a different set of requirements for workers’ comp insurance, which can make things complicated if you have employees in multiple states. Some states, such as Texas, don’t require employers to provide workers’ compensation insurance at all, while others have minimum requirements set by a workers’ compensation board.
Find out which workers’ compensation laws apply, and use a claims management tool like Pulpstream to navigate each workplace accident on a case-by-case basis.
Consider alternatives
In some cases, an employee won’t be eligible for workers’ comp because their job injury falls outside the scope of your workers’ comp policy. If that’s the case, they may still be eligible for a leave of absence under the Family and Medical Leave Act (FMLA), or a workplace accommodation under the Americans with Disabilities Act (ADA.gov).
Other options include short- or long-term disability benefits, which may be available in addition to workers’ comp benefits and can even be collected simultaneously.
Respect employee privacy
Both the ADA and FMLA have strict confidentiality requirements to protect employees’ privacy. The workers’ compensation claims process is a little more complex. Although employee medical records are protected under the Health Insurance Portability and Accountability Act (HIPAA), this doesn’t extend to workers’ comp claims.
According to the U.S. Department of Health and Human Services: “The HIPAA Privacy Rule does not apply to … workers’ compensation insurers … administrative agencies, or employers…. [and] the Privacy Rule permits disclosures of health information for workers’ compensation purposes in a number of different ways.”
In other words, employers have the right to access some employee medical records for workers’ comp purposes, but it’s still important to respect employee privacy and avoid disclosing information to coworkers who don’t have a genuine need to know.
Simplify the Workers’ Comp Claims Process with Pulpstream
The workers’ compensation claims process begins at the first report of an employee’s injury and continues all the way through to the return-to-work process. It may involve communications with an insurance carrier, medical provider, workers’ compensation lawyer, and the division of workers' compensation in your state.
Streamline your workers’ comp claims process by bringing all of your documents and communication channels into one cloud-based platform. With Pulpstream’s incident management and claims management tools, you can administer any type of claim, communicate with insurance adjusters, generate OSHA reports, and more.
Request a demo today to see how it works!
