California WCIRB clarifies position on First Aid Claim reporting

California Worker's Compensation Industrial Relations Board has recently issued a bulletin that clarifies its position on reporting of First Aid Claims to the carrier. In the bulletin dated August 23, 2006, the Board reiterated that the Insured must report all First Aid claims or be in violation of Insurance Code 11755. (click here to see the code).

Many workers have paid physicians and clinics directly for the one time treatment of minor scrapes or bruises to expedite the care of minor injuries. However, the 2005-2006 law changes now require that any physician who provides treatment to an injured worker must report that treatment to the State of California. The Board will then match the medical bills to Carrier Claims numbers. If bills do not have a companion claim number the Carrier and the Employer will be fined.

In an earlier bulletin the Department explained the rational behind the decision.

"Department of Industrial Relations believes there are improper arrangements in place between some medical providers and employers that allow the employer to dictate how injuries are to be classified by the physicians. In some cases, and at the request of the employers, the physicians send the DFR only to the employers and not to the insurance carriers. This arrangement occurs even though the injuries clearly are beyond first aid. This agreement is often marketed to employers as a way to keep premiums from rising or to lower them. Such marketing practices are both improper and may also contribute to possible criminal violations related to premium fraud and the fraudulent denial of Workers Compensation benefits to injured workers."

Many questions arise over what is a First Aid Claim. The Board defines a First Aid Claim as a one-time treatment with full release and no follow-up. One important note to keep in mind, if a First Aid Claim is reported as a notice only and no further bills are reported, the claim will not be reflected in the calculation of the insured's experience modification. The experience modifier is calculated upon costs incurred not the number of claims reported.

Contact your Emplicity representative or call us at 877-476-2339 with questions regarding claims reporting.

*Source: Cedar Hill Insurance Agency


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