A Simplified Look At the Workers’ Comp Claims Process

A Simplified Look At the Workers’ Comp Claims Process


While the workers’ compensation claims process varies by case, the steps every employer and injured worker need to take are relatively the same. These protocols help to expedite the process and protect all involved. As such, it’s essential that those in charge as well as those at risk understand what to expect in case of a work-related injury or illness. To help, here is a simplified look at what workers and employers should do in chronological order.

First things first, it’s important an employee reports the injury right away to the employer. Any and all information relevant to the incident should be included in the report, such as when, where, how and the type of injury. Who to report to varies by organization. It could be a direct supervisor, someone in human resources or even a designated safety representative within the company. Employers should ensure workers are kept informed of who injuries are reported to and apprised of any changes in procedure.

If severe or life-threatening, the injury should be treated by medical professionals immediately. If the injury is not serious, treatment may be performed on-site while the employer assists the injured worker with the necessary forms and reports. The state and jurisdiction of the claim could play a role in medical treatment for job-related injuries. Everyone is encouraged to review the requirements regarding designated networks, medical providers and claim procedures for their specific location.

Next, employers report the injury — along with relevant documentation — to the workers’ comp carrier. Although the requirements of the carrier may vary, employers should be prepared to supply employee information, injury details, medical care reports and other significant pieces of information. The timeliness of the report is also an important consideration. OSHA guidelines stipulate that employers report any inpatient hospitalizations within 24 hours and fatalities within eight hours.

Once the carrier has reviewed the evidence and information in a thorough investigation, the claim is either accepted or denied. Many points are taken into consideration as part of the investigation, with the main one being whether or not the injury occurred within the course and scope of employment.

During this phase, the injured worker, employer and carrier will develop a personalized return-to-work plan together. Accommodations may be made for temporary or even permanent restrictions based on physician recommendations and employee capabilities. At times, an employee may seek legal counsel and pursue a personal injury liability case for adequate compensation.

When the settlement is closed and compensation awarded, a certain amount is allocated for medical care. Said amount is placed into a Medicare Set-Aside (MSA) Account to cover the expenditures. There are rules and restrictions on how the money in an MSA account is spent. It’s advised to seek professional guidance to ensure the final audit of the account goes well.
For further information and a step-by-step breakdown of the process, please see the accompanying resource.

medicare set aside account administration

Infographic provided by MSA Meds, a professional medicare set aside account administration