Insights

WCIRB’s Reporting Requirements of “First Aid” Claims & How This Will Impact Your Experience Modification

March 6, 2017

Claims

By now, most employers have received notification from their insurance carrier that medical costs incurred on first aid claims, even if paid by the employer, must be reported to the insurance carrier as any other medical loss.

Effective Jan. 1, 2017, the insurance commissioner approved  amendments to the California Workers’ Compensation Uniform Statistical Reporting Plan – 1995 (USRP) to clarify the reporting requirements for small, medical-only or “first aid” claims. The reason for this clarification is the WCIRB had concerns that employers (and thus insurance carriers) were under-reporting small medical-only or “first aid” claims which reportedly caused unfairness within experience ratings. By not reporting the claim, the WCIRB indicated it limited an injured worker’s access to medical benefits, thereby creating difficulties in managing a claim that may later deteriorate.

First Aid Sign

The WCIRB  believes that the reporting of all claims will provide an even playing field to insurers, providers and brokers. Now that the WCIRB is explicitly citing first aid in the definition of medical claims and the reporting of losses, the amendments clarify the intent of the regulations.

However, California Labor Code Section 5401 (a) does not obligate the employer to report first aid claims, and Labor Code Section 6409 (a) indicates only a “physician” as defined in California Labor Code Section 5401 (a) has an obligation to report to the employer and insurer.

What Does This Mean for Your Business?

To remain compliant with the WCIRB’s approved amendments, Woodruff Sawyer recommends that all claims for which any medical care is provided by a physician or clinic where a “Doctor’s First Report of Injury” (Form 5021) is produced (including first aid) be reported to your insurance carrier.

The  insurance carrier will include the medical costs of each claim to the WCIRB at the time of unit statistical reporting. It should be noted that no changes have been made to the California Labor Code, nor has any enforcement mechanism been proposed by the WCIRB or the CDI to confirm employers are following the reporting requirements.

Employers are NOT required to provide a claim form (DWC-1) to the injured worker on first aid claims (Labor Code Section 5401 (a)), nor is an employer required to submit the “Employer’s First Report of Occupational Injury or Illness” (Form 5020) on first aid claims (Labor Code Section 6409.1).

OSHA does not require first aid claims be logged for OSHA reporting purposes.

What Types of Injuries Do Not Need to be Reported?

  • An employee cleans a minor wound, applies a Band-Aid or is given over-the-counter medication. Band-Aids and a Tylenol have a cost associated with them, but it is not considered a significant cost and isn’t considered treatment.
  • On-site clinic visits that do not generate a 5021 “Doctor’s First Report of Injury,” and where the medical fee is done on an annual contract basis, i.e., fee cannot be associated with a particular injured worker.
  • On-site mobile medical response units where a non-physician, such as an EMT, evaluates or treats a minor injury.
  • Telephonic nurse triage is not considered treatment, but rather advice only.

Potential Changes to 2019 Experience Modifications – Eliminating the cost of Small Claims from the Formula:

In 2015, the WCIRB formed a working group  that consisted of employers and insurance company professionals with the goal of better understanding the issues and implications surrounding the reporting of first aid claims.

The group agreed that the USRP was not consistently being followed and that the WCIRB should consider eliminating the first $250, $500 or $1,000 from each small claim (< $2,001) from the Ex-Mod calculation.

The WCIRB tested the various thresholds and determined the $500 and $1,000 thresholds eliminated too many claims. The WCIRB determined the elimination of the first $250 will reduce incentive to not report first aid claims without significant loss of plan accuracy, or decrease in the claim-free credit.

What this means is that if an insurer reports a first aid claim with costs of $500, the WCIRB would show this claim as $250 on the Experience Modification Worksheet.

The WCIRB committee is currently reviewing this change and if approved, will be filed with the California Department of Insurance (CDI) in June 2017 along with a proposal to simplify the current Experience Rating formula that would become effective Jan. 1, 2019.

 

 

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