History and Overview
It's not your grandfather's workman's compensation
The 19th and 20th century brought new industrialization and along with it, more frequent worker injuries. Employers were faced with lengthy and costly lawsuits, while workers, forced to prove an employer’s liability, were often left jobless and destitute.
To protect both, in 1911 Washington enacted “no-fault” industrial insurance laws requiring workers’ compensation coverage for the most hazardous jobs. With these laws, neither party had to accept blame for the incident, employers could not be sued, and workers were guaranteed medical benefits and partial wage compensation. In 1937, the law expanded to cover occupational diseases, and in 1971, most classifications of employment in the state were covered.
The program has grown and modernized over time, but the legal framework remains fundamentally the same. Today, L&I is one of four states that administers its own workers’ compensation benefits, either through a public State Fund (covering 2/3 of WA workers) or through self-insured employers (covering 1/3 of WA workers). Other systems, such as federal workers’ compensation and the Longshore and Harbor Workers Act, cover a small percentage of workers in Washington State.
Laws and Rules of WA Workers' Compensation
A medical-legal system
Title 51 Revised Code of Washington (RCW) authorizes L&I to administer workers’ compensation benefits, and only the state legislature can change them. Administrative rules (regulations) in Title 296 of the Washington Administrative Code (WAC), clarify the intent of the RCWs. Rules are based on multiple factors, such as scientific evidence that supports the best in clinical care, fiduciary responsibility for premiums, community standards of care, occupational best practices, safety and efficacy of emerging technologies, and input from our advisory committees. These influence the treatment you can or cannot provide to help workers have a successful recovery and return to work.
Two Kinds of Claims
State Fund and Self-Insured
In workers’ compensation, a claim is similar to a patient’s chart containing important information about the worker and employer. To file the correct claim form and contact the right person(s), you must know whether your patient’s employer is covered by the Washington State Fund or if the employer is self-insured, meaning they pay for benefits with their own funds. You can check if an employer is self-insured at Find a Self-Insured Employer.
For employers who pay premiums into L&I’s Washington State Fund, you will file a Report of Accident (ROA) and contact an L&I claim manager.
For self-insured employers, you will file the Self Insurer Accident Report (SIF-2) and the Provider’s Initial Report (PIR). The claim manager will be work for either the SIE or a third-party administrator (TPA).
It must have happened on the job
The department relies on the attending provider to help determine whether a worker’s medical condition is related to an injury or exposure that occurred while performing his or her job duties. By law, a claim can be accepted only if the provider states that a condition is work-related on a “more probable than not” basis, meaning greater than 50 percent certainty. This would be indicated by circling either “yes” or “probably” on the accident report. By applying your best clinical judgment and providing accurate medical documentation, you will help the claim manager make a proper allowance decision.
Medical Necessity and Treatment Limits
Liability limits care
L&I and self-insured employers (SIEs) are liable to cover only “proper and necessary” care that is related to diagnosis and treatment of an “accepted condition” on the claim. This means the condition is a proximate result of a workplace injury or disease. Care must be curative or rehabilitative and must stop when maximum medical improvement occurs (same as “fixed and stable”). Occasionally, the insurer will cover temporary treatment of an unrelated condition if it was aggravated by the injury or disease, or if it is impeding recovery of the accepted condition.
Confidentiality and HIPAA
It's different for workers' comp
When your patient signs the Report of Accident or the Provider’s Initial Report form, he or she is also signing a medical authorization permitting you to release, without liability, the worker’s medical records to L&I or the self-insured employer. This allows an exchange of information and eliminates the need for authorization forms if additional information is requested from you (RCW 51.36.060). The authorization to release medical records extends to L&I’s representatives (such as the department’s utilization review vendor, medical case managers, and vocational counselors), and to your patient’s State Fund employer. Learn more about HIPAA and L&I.
Fraud, Claim Suppression, or Unsafe Workplaces
Who ya gonna call?
L&I takes fraud seriously and violating laws can have significant consequences. Preventing fraud is always preferable. APs are in a key position to spot fraud and help L&I take appropriate action. Unfortunately, some providers have themselves been part of a fraud scheme. It’s everyone’s responsibility to make sure our workers’ compensation system is used appropriately.
Fraud activities can appear in different forms, such as:
- A worker filing a claim when not actually injured on the job,
- A worker collecting time-loss benefits while working or when not entitled,
- Employers who try to prevent workers from filing claims or directing to whom their workers should go for care, or
- Providers billing for services not provided.
Suppression of workers’ compensation claims (RCW 51.28.010): No employer shall engage in claim suppression by inducing employees to fail to report injuries; inducing employees to treat injuries in the course of employment as off-the-job injuries; or acting otherwise to suppress legitimate industrial insurance claims.
If you suspect a worker is being discouraged from filing a claim, you and/or the worker can file a Claim Suppression Complaint form or the worker can call 1-866-324-3310 or 360-902-9155.
If you are concerned that a patient’s workplace is not safe, L&I urges you to report this to the service location closest to you. You can discuss your concerns with a safety or industrial hygiene supervisor. If appropriate, the supervisor may ask you to file a complaint, and the workplace will be inspected.
Record Storage and Retention
Boring but important
L&I may audit records of the services you provided your patient. The following list will help you comply with record storage and retention requirements:
- All medical records that show the extent of services provided must be maintained for at least five years. In addition, the level and type of services for which you seek payment must be documented and maintained. (WAC 296-20-02005)
- X-rays must be kept for at least 10 years. (WAC 296-20-121)
- X-rays and other imaging studies must be returned to the worker, hospital or the office that provided them, unless they have directed you not to return them.