FirstCARE: First Aid Guidelines for Employers

Saturday, September 25, 2004 | 0

First aid has been a topic of concern for many employers because of a recent memo from the California Department of Insurance and State Compensation Insurance Fund (SCIF) that was sent to SCIF policyholders and Doctors. The memo said:

The definition of First Aid is 'any one time treatment of minor scratches, cuts, burns, splinters, or other minor industrial injury.' This definition is found in Section 5401 of the Labor Code.

The law requires all physicians to complete and submit the Doctor's First Report (Form 5021) within five (5) working days to the workers' compensation carrier or directly to the claims administrator for the self-insured employer. This law applies to all workers' compensation injuries, including first aid, whether or not an Employee Claim Form (DWC-1) has been filed. The Doctor's First Report should not be sent first to the employer. To assist in this process, the employer should promptly respond to every physician's request to identify their claims administrator.

The Department of Insurance announcement, which we have enclosed, states that offending physicians and employers are subject to fraud prosecution. Therefore, State Fund urges all physicians and employers to comply with these requirements.

Upon receipt of the Doctor's First Report, State Fund will send a copy to the Department of Industrial Relations as required. At that point, State Fund will determine whether the injury/illness meets the Labor Code definition of first aid. If it does, the Doctor's First Report will be sent to the employer along with related bills upon confirmation that the employer wishes to make payments for the first aid treatment."

How do Small Claims Impact My Premium?

First, let me make it clear that it is not up to you to decide what is, and what isn't a first aid claim. That is the determination of the treating physician. But, given that, what is the potential impact for first aid claims on your ultimate premium calculation?

All small claims individually valued at $2,001 and under are grouped together for the purposes of calculating your ex-mod and count dollar for dollar against your ex-mod. All claims over $2,001 are discounted; the higher the cost of the claim, the more the claim is discounted in its impact on your ex-mod.

Consider the following:

Small claims under $2,001 cost your company anywhere from 300% to as much as 700% of the original claims cost due to the increase in your ex-mod over the next three year rating period. Compare that to the average indemnity claim of $50,000 that typically costs you 200% of the original cost.

200% is bad enough, but with many small claims costing employers 500% of the original claim cost on average, you're certainly better off not submitting these claims and paying for them whenever you legally can.

An injury treated as first aid need not be recorded as an injury; therefore, it is not counted toward the employer's ex-mod. One way to reduce claim frequency is to have as many minor injuries as appropriate treated as first-aid cases.

First, you'll need to locate a clinic or physician that understands workers' comp procedures, especially the importance of treating, where appropriate, your employees' injuries as first-aid cases. Inform the clinic or physician that you will pay for first-aid treatments. Don't take for granted that the clinic or physician will treat first-aid injuries as first-aid cases and bill you directly.

What about State Fund's Policy?

The law requires that the treating Doctor submit a Doctor's First Report on all injuries, whether first aid or not. However, the law does not require that the treating Doctor submit the bills for first aid claims to the carrier for payment. Once the bills are submitted to State Fund and paid, there is little recourse that can be taken to reverse the payment. For this reason, we are suggesting that employers continue to have all bills for first-aid sent to them directly for payment.

What exactly is First-Aid?

The California Labor Code describes first-aid as:

A one time treatment and subsequent observation of minor injuries and are not considered reportable IF the injury does not involve loss of consciousness, restriction of work or motion, or transfer to another job.(Emphasis added.)

FIRST-AID:

* Antiseptics, application of, on first visit to a doctor or nurse.
* Bandaging on any visit to a doctor or nurse.
* Burns of first degree.
* Compresses, hot or cold, on first visit to a doctor or nurse only.
* Elastic bandage, use of, on first visit to a doctor or nurse only.
* Foreign bodies, not embedded; irrigation of eye for removal.
* Foreign bodies, removal from wound by tweezers or other simple techniques.
* Non-prescription medications, use of.
* Observation of injury on second or subsequent visit.
* Ointments applied to abrasions to prevent drying or cracking.
* Tetanus shots, initial or boosters alone.
* Hospitalization for observation (no treatment other than first aid).
* X-ray which is negative.

State Fund's claims unit expands on the term First Aid care:

"First aid care is ... care that does not require professional attention but could easily be given at home or at the worksite given the availability of supplies typically found in someone's medical cabinet."

Our definition is "If you can treat it at Rite Aid, then, it's first aid." What's Not Considered First-Aid?

Quick Check:

* Cumulative Trauma (CT) Injuries
* Any Chiropractic Care
* Any Time Loss from Work Other than Date of Injury (D.O.I.)
* Prescription Medication (Other than Given as Samples by Doctor)
* When an employee claim form is provided (signed or unsigned)

If injury or illness involves:

* Loss of consciousness (regardless of medical/first aid treatment).
* Restriction of work or motion (regardless of medical/first aid treatment).
* Transfer to another job (regardless of medical/first aid treatment).
* Termination of employment (regardless of medical/first aid treatment).
* Antiseptics applied on second or subsequent visit to a doctor or nurse.
* Burns of second or third degree.
* Butterfly sutures.
* Compresses, hot or cold, on second or subsequent visit to a doctor or nurse.
* Cutting away dead skin (surgical debridement).
* Diathermy treatment.
* Foreign bodies, removal if embedded in eye.
* Foreign bodies, if removal from wound requires a physician because of depth of embedment, size or shape of object(s) or location of wound.
* Infection, treatment for.
* Use of prescription medications.
* Soaking, hot or cold, on second or subsequent visit.
* Sutures (stitches).
* Whirlpool treatment.
* X-ray which is positive.
* A hearing loss average of 10 decibels or greater in either ear.
* Musculoskeletal injuries that a licensed physician or health care professional objectively identified and diagnosed.

Important note: an employee claim form will automatically start a claim!

The receipt of an employee claim form gives the Workers' Compensation Appeals Board (WCAB) jurisdiction. No employee claim form should be given to an employee until it has been decided if the claim should be filed or be treated as first aid.

* If an employee claim form is filed with carrier, a 'medical only' file will be made up.

* Upon receipt of additional billing or reports of continued treatment, the carrier will immediately initiate a claim.

* The treating physician is still required to file an injury report with carrier on first aid cases.

by Brent Heurter, Founder and Chief Solutions Officer of ClearComp, a workers' compensation alternative for companies that desire to control and reduce their workers' compensation costs. Brent can be reached at 888.CLEAR.89 or email brent@clearcomp.com.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.