Workers’ Compensation Division Penalties - Who Needs ‘Em? How to Avoid Them WCD Compliance Section Investigations and Sanctions Unit Investigations and Sanctions Sanctions Unit Compensation penalties Civil penalties Benefit suspensions Much, much, more! Investigations and Sanctions Investigations Inducement Accepting Notice Claims Handling Practices • ORS 656.745 penalties Authority The Law • ORS = Oregon Revised Statutes • Chapter 656 = Workers’ Comp law • Example: ORS 656.745 Authority Administrative Rules • OAR = Oregon Administrative Rules • Chapter 436 • Division 60 covers claims handling By insurers and employers Worker Fraud Insurer SIU See ORS 656.990 DA referral WCD cooperates Fraud Investigations Insurer must investigate before they can issue a claim denial. Fraud Investigations Employer is required to cooperate. It’s not Always Fraud Insurers need to know that, too. 83% of disabling claims are accepted. Misstatements cause delays and could cost $$$. What can Employers do? Consider red flags Pay attention Write it down Call your insurer Red Flags Concurrent employment Unwitnessed accident Accident timing Worker history Pay Attention! Know your workers Hobbies and skills Work ethic Family Write it Down It may be months before action is taken. Call Your Insurer Details = $$$ Physical Description Vehicles Dwelling Housemates Avocations What can Workers do? The truth, and nothing but the truth. Insurers Employers Doctors Attorneys Judges Investigations Issues Worker complaints • Inducement to not file ORS 656.745 OAR 436-060-0200 Investigations Issues Worker complaints • Employers often misunderstand the small claims provisions in ORS 656.262(5) OAR 436-060-0055 Investigations Issues Worker Complaints • First aid OAR 436-060-0010(4) BREAKING NEWS! Vsetecka v. Safeway Stores, Inc. (WCB 00-02916; CA A113353; SC S49908) Says if the worker writes entry in first aid log, you may have been given notice. Read ORS 656.265, take two aspirins & call your attorney! Investigations Issues Worker complaints •Bonus programs Investigations Issues WCD supports bonus programs, But. . . Investigations Issues • Inducements to not file ORS 656.745 OAR 436-060-0200 Investigations Issues More Worker complaints • Accepting notice of claim ORS 656.265 OAR 436-060-0010(1) Investigations Issues More worker complaints • A signed 827 is a claim! ORS 656.265 OAR 436-060-0010(2) Investigations Issues Insurer & provider complaints • Injured worker failure to cooperate ORS 656.262(14) Investigations Issues Insurer & provider complaints • Employer failure to cooperate ORS 656.262(3)(b) Investigations Issues Insurer & provider complaints • Treatment disputes go to MRU Investigations Issues Chiropractor treatment 30 days, 12 visits Investigations Issues Nurse Practitioners OAR 436-010-0005(3) 90 days of treatment 60 days of time loss Investigations Issues Insurer & provider complaints • Premium fraud • Provider billing fraud Investigations Issues Employer complaints • Insurer failure to process • Other service-related issues BEST PRACTICES Best Practices - Employers Post current Compliance Notices It’s the law! ORS 656.056 Best Practices - Employers Keep an incident log available for review by the Dept. OAR 436-060-0010(4) Best Practices - Employers Employers must accept all notices of claim and provide receipt forthwith Best Practices - Employers Instruct workers that they have choice of physician Even if there is a drug-test policy Best Practices - Employers New hires read and sign off on reporting procedures Best Practices - Insurers Educate! Correct reporting procedures Immediate access to first injury report forms (801 forms) Best Practices • Promptly return phone messages from employers, insurers, and WCD • Avoid civil penalties for non- response! Penalties and Actions Up to $2000 per violation ORS 656.745 OAR 436-060-0200 WCD is Here to Help For assistance with how to proceed with a claim, call the Ombudsman for Injured Workers (800) 927-1271 WCD is Here to Help For questions about laws and rules call our Benefit Consultation Unit (BCU) at (800) 452-0288 Or ask for Investigations and Sanctions Unit at (800) 452-0288 Investigator Dwayne Edsinga at ext. 7685 Manager Bob Hamre at ext. 7654 Questions? Thank You!
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