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!