Omar Elhakeem
HRM 361 Human Resource
04/15/2015
Workers Compensation: Claims Human Resources is here to ensure employees receive benefits and work-related laws for the workers compensation claim. If the company is large enough and has its own HR department, normally the HR management will be in charge of the workers compensation claim. Human resources role is to make sure that an injured employee receives medical care and is treated fairly. They are also responsible for making sure employees receive protection under any collective bargaining agreement in place, for example, the American with Disabilities Act, Family and Medical Leave Act, and any state laws or company benefit plans. They will also help with accommodations and training needed to assist the return of the employee to his job as soon as possible. Denied claims are those that were deemed not covered by the claim administrator after review. If one receives decision with denied claim, it can be challenged to review its validity. Through this claim you can represent yourself or hire an attorney, which will cost to get the process complete. One of the most common reasons that workers compensation claims are denied is that the claim was not reported or filed on time. (Laurence) This can still be reviewed and the claim will be seen in front of the workers compensation judge to decide the ruling. In order to have the case heard by the judge, the application for adjudication of claim must be submitted to the Department of Workers Compensation office and shortly after the case number would be provided. Then to have the hearing before the judge the Declaration of Readiness to Proceed needs to be completed and from there a court date will be chosen. At the hearing the judge will try and reach a settlement with the defendant and lawyer. If there is not a settlement, it will then go to trial and will have to testify in front of another judge at another date. After the trail the judge will submit decision by regular mail within about 30 and 90 days after the trial. At this point if you receive another denied decision and would like to continue to fight the claim, the Petition for Reconsideration must be completed and the process will be reviewed. It could be a very long and drawn out process if one tries to fight their claim in court. It not only takes a lot of time but can also cost you if you hire an attorney or have to be reevaluated at the hospital. Also while the process is all going there is no disability payments that are being dispersed or medical treatments being paid for. This can make things very challenging for the employee to manage health and bills at the same time. When false claims are placed it makes it more difficult for the claims administrator and ruins the program for the honest claimant. The fraud can occur either when the employee makes up an injury or on the other hand it can come from the doctors and physicians that are paid off to writing incorrect evaluations. When the claim is finalized the insurance company or state is caught paying for a fraudulent bill. In 1991 the Workers Compensation Fraud program began, and the legislation making any fraud claims a felony. Then the Fraud Assessment commission was created to enforce and prosecute unlawful activity. In Fiscal Year 2012-13, the district attorneys reported a total of 815 arrests, which also included the majority of Fraud Division arrests. During the same timeframe, district attorneys prosecuted 1,329 cases with 1,545 suspects, resulting in 721 convictions. Restitution of $24,862,189 was ordered in connection with these convictions and $4,890,396 was collected during Fiscal Year 2012-13. The total chargeable fraud was $247,922,658, representing only a small portion of actual fraud since so many fraudulent activities remain to be identified or investigated. (Jones) There are thousands of people that are getting paid for not going work with workers compensation and it is costing the state and