Understanding Workers' Compensation: A Comprehensive Guide, Exams of Nursing

Download Understanding Workers' Compensation: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! 1 Chapter 18 Workers’ Compensation MULTIPLE CHOICE 1. The only state that allows private employers to choose whether or not to provide workers’ compensation is: a. Maryland. b. New York. c. Texas. d. Wisconsin. Answer: c HISTORY OF WORKERS’ COMPENSATION 2. OSHA stands for the: a. Occupational Standards for Health Administration. b. Optional Safety and Health Act. 2 c. Occupational Safety and Health Administration. d. Optional Standards for Health Act. Answer: c HISTORY OF WORKERS’ COMPENSATION 3. Employers that are regulated by OSHA include: a. manufacturers. b. church organizations. c. independent contractors. 5 c. Energy Employees Occupational Illness Compensation Program Act. d. Longshore and Harbor Workers’ Compensation Act. Answer: d FEDERAL WORKERS’ COMPENSATION PROGRAMS 7. All states provide workers’ compensation coverage for: a. medical expenses only. b. lost wages only. c. medical expenses and lost wages. d. death benefits only. Answer: c STATE WORKERS’ COMPENSATION PLANS 8. Employers can obtain workers’ compensation insurance policies through all of the following EXCEPT: a. federal programs. b. state workers’ compensation funds. c. private insurance carriers. 6 d. self-funded plans. Answer: a STATE WORKERS’ COMPENSATION PLANS 9. Examples of compensable injuries include all of the following EXCEPT: a. falls in the company parking lot. b. injuries incurred while working on a home improvement project using tools borrowed from work. 7 c. injuries that occur in a company restroom, break room, or cafeteria. d. stress injuries caused by work conditions. Answer: b OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 10. A health problem that results from exposure to a workplace health hazard such as chemical fumes is a(n): a. terminal disease. b. workplace injury. c. workers’ compensation accident. d. occupational disease. Answer: d OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 11. A worker may NOT receive benefits for a generally covered injury if any of the following are true EXCEPT the: a. injury occurred while the worker was intoxicated. 10 14. An employee who is injured on the job, requires treatment, is NOT able to return to work, and is NOT expected to be able to perform his or her regular job in the future is categorized as having an injury: a. without disability. b. with temporary disability. c. with permanent disability. d. requiring vocational rehabilitation. Answer: c OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 11 15. An employee who is injured on the job, requires treatment, and is able to return to work after retraining is categorized as having an injury: a. without disability. b. with temporary disability. c. with permanent disability. d. requiring vocational rehabilitation. Answer: d OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 16. The category of workers’ compensation benefits that will pay for medical expenses only is injury: a. without disability. b. with temporary disability. c. with permanent disability. d. requiring vocational rehabilitation. Answer: a 12 OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 17. Workers’ compensation death benefits paid when a worker has died as a result of an on-the-job injury are paid to the employee’s: a. designated beneficiary. b. children under age 18 only. c. spouse only. d. spouse and dependent children. Answer: d 15 Answer: c TREATING DOCTOR’S RESPONSIBILITIES 21. The report that affirms that a worker has been released from medical treatment and is fit to return to work and resume normal job responsibilities is the: a. interim report. b. status report. c. final report. d. rehabilitation report. Answer: c TREATING DOCTOR’S RESPONSIBILITIES 22. An impartial physician who helps to resolve a workers’ compensation claim dispute is known as the: a. treating doctor. b. designated doctor. c. physician of record. d. primary care physician. 16 Answer: b TREATING DOCTOR’S RESPONSIBILITIES 23. In the event that a worker and insurance company decide to engage a different designated doctor than the one named by the state WC Department, they must agree to select the new doctor within: a. 5 business days of the date of the state’s notice. b. 1 week of the date of the state’s notice. 17 c. 10 days of the date of the state’s notice. d. 30 days of the date of the state’s notice. Answer: c TREATING DOCTOR’S RESPONSIBILITIES 24. After the designated doctor has examined the worker, all communication with him or her about the worker’s injury or condition must be made through the: a. injured worker. b. employer. c. workers’ compensation office handling the claim. d. treating doctor. Answer: c TREATING DOCTOR’S RESPONSIBILITIES 25. Maximum medical improvement is the earliest point in time that a worker’s injury or illness has improved as much as it is likely to improve or: a. 52 weeks from the date the worker became eligible to receive income benefits. b. 60 weeks from the date the worker became eligible to receive income benefits. 20 c. 90 days from the date of notice. d. 120 days from the date of notice. Answer: c DISPUTING MAXIMUM MEDICAL IMPROVEMENT OR IMPAIRMENT RATING 29. The four types of workers’ compensation benefits are: a. medical, disability, health, and death. b. medical, income, disability, and death. 21 c. medical, income, death, and burial. d. disability, suffering, death, and burial. Answer: c TYPES OF WORKERS’ COMPENSATION BENEFITS 30. Medical benefits for an injured worker begin: a. immediately and end 1 year after the date of the injury. b. immediately and have no specific time limit. c. after a 3-day waiting period and end 1 year after the date of the injury. d. after a 3-day waiting period and have no specific time limit. Answer: b TYPES OF WORKERS’ COMPENSATION BENEFITS 31. All of the following are types of income benefits EXCEPT: a. temporary income benefits. b. supplemental income benefits. c. surviving dependents’ income benefits. 22 d. lifetime income benefits. Answer: c TYPES OF WORKERS’ COMPENSATION BENEFITS 32. To be eligible to receive temporary income benefits, an injured worker must have lost some or all income for more than: a. 3 days. b. 7 days. c. 2 weeks. 25 d. third-degree burns covering the majority of either both hands or one hand and the face. Answer: a TYPES OF WORKERS’ COMPENSATION BENEFITS 36. The spouse of a worker killed on the job is eligible for death benefits: a. for life regardless of whether or not the spouse remarries. b. until the spouse remarries. c. until the spouse remarries plus a lump sum payment of 1 year. d. until the spouse remarries plus a lump sum payment of 2 years. Answer: d ELIGIBLE BENEFICIARIES 37. Dependent children of a worker killed on the job are eligible to receive death benefits until they: a. obtain a full-time job. b. reach age 18. 26 c. reach age 18, or 25 if enrolled as a full-time college student. d. reach age 21. Answer: c ELIGIBLE BENEFICIARIES 38. If an individual has both an employer-sponsored disability plan and a government- sponsored plan: a. the government plan is primary, and the employer plan would supplement the benefits. 27 b. the employer plan is primary, and the government plan would supplement the benefits. c. only the employer plan would pay benefits. d. only the government plan would pay benefits. Answer: a DISABILITY COMPENSATION PROGRAMS 39. An individual who becomes disabled due to a non-work-related injury may be eligible for which type of benefits paid by a private plan or government program? a. Medical and income benefits b. Medical benefits c. Income benefits d. Income and death benefits Answer: c DISABILITY COMPENSATION PROGRAMS 40. Social Security Disability Insurance (SSDI) is paid for by: a. workers’ payroll deductions matched by employer contributions. 30 c. 95 days of the date of service. d. 120 days of the date of service. Answer: c FILING INSURANCE CLAIMS 44. A workers’ compensation insurance carrier must pay, reduce, deny, or determine to audit a claim no later than the: a. 30th day after receipt of the claim. 31 b. 45th day after receipt of the claim. c. 95th day after receipt of the claim. d. 120th day after receipt of the claim. Answer: b FILING INSURANCE CLAIMS 45. If a workers’ compensation claim is denied, the provider can request a review by: a. the state workers’ compensation insurance fund. b. the state insurance commissioner. c. a medical examination review committee. d. an independent review organization. Answer: d INDEPENDENT REVIEW ORGANIZATIONS 46. An employer who misrepresents the amount of payroll or classification of employees in order to reduce workers’ compensation costs commits: a. premium abuse. b. premium fraud. 32 c. benefit abuse. d. benefit fraud. Answer: b FRAUD 47. A worker who works full time at an unreported job while collecting workers’ compensation benefits commits: a. benefit abuse. 35 a. capitation rates. b. charge-based fees. c. the Medicare Fee Schedule. d. usual and customary charges. Answer: c CALCULATING REIMBURSEMENTS FILL-IN-THE-BLANK 51. The earliest workers’ compensation programs were opposed by organized labor because they did not encourage a(n) work environment. Answer: safe HISTORY OF WORKERS’ COMPENSATION 52. The legislation that provides workers’ compensation benefits to civilian employees of the United States government is the . Answer: Federal Employees’ Compensation Act (FECA) FEDERAL WORKERS’ COMPENSATION PROGRAMS 53. Each regulates and administers its own workers’ compensation program. 36 Answer: state STATE WORKERS’ COMPENSATION PLANS 54. The category of work-related injury that requires treatment, although the injured worker is able to return to work within several days, is injury . Answer: without disability OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 37 55. Vocational rehabilitation involves the of an injured employee to enable him or her to return to the workforce. Answer: retraining OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 56. The provider from whom an injured worker receives medical care is referred to as the doctor or of record. Answer: treating; physician INJURED WORKER RESPONSIBILITIES AND RIGHTS 57. The rating describes the degree of permanent damage done to the worker’s body as a whole. Answer: impairment TREATING DOCTOR’S RESPONSIBILITIES 58. are Workers’ Compensation Department employees who can help the worker with his or her claim once a proceeding has been scheduled. Answer: Ombudsmen OMBUDSMEN 40 HISTORY OF WORKERS’ COMPENSATION 62. Law that provides workers’ compensation benefits to employees of the United States government. Answer: e HISTORY OF WORKERS’ COMPENSATION 63. Government program that provides income benefits to people who cannot work because of a medical condition lasting 1 year or more. Answer: g 41 DISABILITY COMPENSATION PROGRAMS 64. Billing by a provider for a more expensive service than the one performed. Answer: a FRAUD 65. Illegal incentives paid for patient referrals. Answer: j FRAUD 66. A sign that suggests that some type of illegal behavior may be occurring; triggers a closer review of a claim or situation. Answer: f FRAUD 67. Physician orders unnecessary treatments or tests to enable billing for higher fees. Answer: h FRAUD 68. Providers collude with the insurance company to defraud the employer. Answer: c FRAUD 69. Physician does NOT provide a sufficient level of treatment because of a fixed capitation payment arrangement. 42 Answer: i FRAUD 45 75. If a worker failed to obey safety procedures and was injured on the job, he or she would be eligible for workers’ compensation. Answer: False OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 76. An injured worker may sue his or her employer after receiving workers’ compensation benefits. Answer: False INJURED WORKER RESPONSIBILITIES AND RIGHTS 77. A Work Status Report must be sent in with the insurance claim each time the injured worker is seen by the treating doctor. Answer: True TREATING DOCTOR’S RESPONSIBILITIES 78. An injured worker who disagrees with the maximum medical improvement date or the impairment rating assigned by a physician must dispute the rating within 90 days. Answer: True 46 DISPUTING MAXIMUM MEDICAL IMPROVEMENT OR IMPAIRMENT RATING 79. Ombudsmen can help present facts and evidence at dispute- resolution proceedings but cannot give legal advice in a workers’ compensation case. Answer: True OMBUDSMEN 80. Medical benefits replace a portion of any wages a worker loses because of a work-related injury or illness. 47 Answer: False TYPES OF WORKERS’ COMPENSATION BENEFITS 81. Temporary income benefits are paid if the injury or illness causes the worker to lose income for more than 7 days. Answer: True TYPES OF WORKERS’ COMPENSATION BENEFITS 82. Eligibility to receive supplemental income benefits ends 365 days from the date of injury. Answer: False TYPES OF WORKERS’ COMPENSATION BENEFITS 83. Eligible children can receive death benefits until age 18, or age 25 if they are a full-time college student. Answer: True ELIGIBLE BENEFICIARIES 84. A spouse is eligible to receive death benefits for life unless he or she remarries. Answer: True 50 90. Medical records for workers’ compensation cases are to be kept separate from a patient’s regular medical records. Answer: True MEDICAL RECORDS SHORT ANSWER 51 91. What is occupational disease? Answer: Occupational disease is a health problem or illness that results from exposure to a workplace health hazard, such as dust, gases, fumes, radiation, repetitive motion, and loud noises. OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 92. List the five categories of work-related injuries. 52 Answer: The five categories are injury without disability, injury with temporary disability, injury with permanent disability, injury requiring vocational rehabilitation, and injury resulting in death. OVERVIEW OF COVERED INJURIES, ILLNESSES, AND BENEFITS 93. What is a Work Status Report, and who completes it? 55 Answer: The injured worker is responsible for informing the employer of a work-related injury or illness within 30 days of the injury or within 30 days of realizing that an injury or illness may be the result of his or her employment. INJURED WORKER RESPONSIBILITIES AND RIGHTS 97. What is the time frame for filing a workers’ compensation claim? Answer: A provider must submit claims to the insurance carrier on or before the 95th day after the date of service. FILING INSURANCE CLAIMS 98. What is meant by insurance fraud? 56 Answer: Insurance fraud is knowingly or intentionally misrepresenting or concealing information for the purpose of denying benefits, obtaining benefits, or profiting in some way from the deceit. FRAUD 99. What is the penalty for workers’ compensation fraud? 57 Answer: Punishment for fraud can include fines, orders for restitution, and imprisonment. FRAUD 100. How is reimbursement calculated for workers’ compensation claims? Answer: When the workers’ compensation policy is not a managed care plan, fees for services are based on the Medicare Fee Schedule (MFS); the MFS fee is multiplied by a certain percentage determined by each state to arrive at the billable fee. CALCULATING REIMBURSEMENT