L&I Glossary of Terms

 

Below is a glossary of terms for the general use of injured workers and their providers. It provides definitions of common terms employed in the Washington state industrial insurance system.

 

A

 

Ability to Work Assessment (AWA): A vocational-rehabilitation service that provides L&I information to make an appropriate determination regarding workers employability or eligibility for vocational rehab services. It may also help injured workers plan for the future by identifying their return-to-work options. These assessments are done by private vocational counselors, under the direction of the CM. AWAs must be reviewed and approved by a vocational specialist on staff at L&I.

 

Accident Year: Method for grouping claims for analysis that all happen to have the same year of accident-causing injury or disease. Useful for grouping similar types of claims for comparisons.

 

Account Services: A section within L&I that supports employers and confirms basic insurance policy information for those insured by the State Fund.

 

Accident Fund: The portion of workers' compensation premium that pays for time-loss compensation, Permanent Partial Disability (PPD) and pension benefits. Employers pay 100% of the premium for this fund.

 

Activity Prescription Form (APF): Form used by the treating physician to describe the limits of physical activity that should be observed by the injured worker during the healing process. An APF is required to be sent by the physician immediately after the first office visit and periodically during treatment as the patient’s condition changes.

 

Adjudicator: Another term for a Claim Manager. Often used specifically to refer to the L&I personnel who manage claims of self-insured employers.

 

Appeal: An application to the BIIA for review of an L&I decision.

 

Association of Workers' Compensation Boards of Canada (AWCBC): A non-profit organization founded in 1919 to facilitate the exchange of information among Canadian Workers' Compensation Boards and Commissions.

 

B

 

Board of Industrial Insutance Appeals (BIIA): The Board of Industrial Insurance Appeals is a court-like agency that hears appeals of workers’ compensation disputes; other appeals are also processed, such as crime-victim benefits. The BIIA handles all aspects of workers’ compensation disputes, including disputes over, among other things, claims decisions, premiums, and medical fee amounts and payments.

 

C

 

Claim: A general term that refers to the rights and benefits owing as a result of a workers’ compensation injury that is covered by Washington’s workers’ compensation laws.

 

Claim and Account Center (CAC): Online services that are available through secure access provided to registered users by My Secure L&I. Services include: checking the status of claims; sending information to L&I, such as a secure message to a CM; checking the status of an employer account; and viewing information about retro participants. Available to L&I stakeholders including: injured workers and their authorized delegates; legal representatives; health care providers; employers; third-party administrators; retro participants; and vocational counselors.

 

Claim Consultant: A senior CM who works on a team dedicated to handling reviews of claims that are appealed to BIIA. This position determines if the appeal will be re-assumed after appeal and handles the disposition of the re-assumed case. Consultants also provide general information concerning workers’ compensation to CM units, upon individual request.

 

Claim Manager (CM): A staff member of L&I, more formally known as a “Workers’ Compensation Adjudicator,” or “WCA,” with responsibility for managing claims for benefits under Washington’s workers’ compensation laws. Most often, “Claims Manager” or “CM” refers to the manager of a State-Fund claim; the L&I staff member who manages a Self-Insured claim is typically referred to as an “Adjudicator.”

 

COHE: The Centers of Occupational Health and Education work with medical providers, employers, and injured workers in a community-based program. COHEs seek to improve injured worker outcomes and reduce disability by training providers on occupational medicine principles and coordinating RTW and other aspects of cases. There are currently 6 COHEs in Washington.

 

D

 

Department: Another term for L&I.

 

Director: The head of the Washington Department of Labor and Industries. In addition to Washington’s workers’ compensation system, the Director is responsible for, among other things, administering the Washington Industrial Safety and Health Act (WISHA) and enforcing Washington’s child labor and wage and hour laws.

 

Disability: As commonly used in workers’ compensation, this refers to the inability to perform certain jobs, and is typically the basis for the payment of lost-time compensation benefits. The degree of the physical impairment and the disability it causes for an individual are not always closely related. For example, a small impairment (tip of finger amputated) may destroy a career for one person, while a major impairment (leg amputated) may not have any effect on the career of another person. Other laws, such as the Americans with Disabilities Act, or Social Security Disability Insurance, use other specialized meanings.

 

Disability Management: Used to refer to the panoply of services and interventions designed to minimize disability caused by a workers’ compensation injury. Compensation systems that excel in disability management are characterized by specific practices that facilitate early, safe, and durable return-to-work outcomes for injured workers.

 

E

 

Early Intervention (EI): Early intervention is a vocational service that is used to help an injured worker return to work, or continue to work for the employer of injury or their current employer. It is used when there is an immediate and specific opportunity for return to work.

 

Employability: The standard used to determine a worker’s eligibility for certain vocational services, specifically a Retraining Plan. (See “Retraining Plan.”) Also used in determining eligibility for a pension (see “Pension”).

 

Employer Representative: A workers’ compensation specialist who assists employers with their workers’ compensation programs, including disability management and resolving process issues with CMs. Typically, Employer Representatives work for Retro Groups, Individual Retro Employers, or independent firms that provide services to such stakeholders.

 

F

 

FileFast: FileFast is an L&I system for workers and medical providers to report worker’s compensation claims online 24 hours a day. The FileFast unit also accepts phoned-in accident reports. FileFast is available to workers, health-care providers, and employers through the Claim and Account Center to users that have registered accounts with My Secure L&I.

 

Fixed and Stable: See "Maximum Medical Improvement."

 

I

 

Indemnity Payments: Payments of benefits designed to compensate for the loss of earnings due to missing work caused by a workers’ compensation injury or death.

 

Independent Medical Examination (IME): This is an examination by a doctor selected by the CM and instructed to provide certain medical opinions regarding a particular claimant. Typical opinions involve the need for further treatment, whether MMI has been reached, or whether an impairment rating should be given. Complying with an IME is compulsory for the injured worker.

 

Individual Retro Employer: A single employer who participates alone in the L&I Retro Program. An Individual Retro Employer will use either a skilled employee or a third party expert to monitor and intervene on its claims.

 

Insurance Services Division: The division within L&I responsible for administering the Washington system of workers’ compensation insurance. Headed by L&I Assistant Director.

 

International Association of Industrial Accident Boards and Commissions (IAIABC): A not-for-profit trade association representing government agencies charged with the administration of workers' compensation systems throughout the United States, Canada, and other nations and territories. Founded in 1914, the stated mission of the IAIABC is to advance the efficiency and effectiveness of workers' compensation systems throughout the world.

 

K

 

Kept-on-Salary (KOS): Situation in which an employer voluntarily continues to pay wages and benefits after an injury even though the worker is unable to perform normal duties. This continuation of wages avoids triggering time loss benefit payments by the State Fund, which in turn saves the employer insurance premium expenses. This practice is encouraged by L&I.

 

L

 

L&I: The Washington Department of Labor and Industries, which is generally responsible for administering Washington’s workers’ compensation laws. Among other things, L&I has responsibility for processing workers’ compensation claims against the State Fund; authorizing certain employers who elect to self-insure their workers’ compensation losses; and monitoring and managing workers’ compensation claims of employees who work for self-insured employers.

 

LINIIS: The core claims management information system used by L&I CMs in day-to-day activities. LINIIS is a mainframe system accessed through pre-defined prompts.

 

Loss of Earning Power (LEP): Earning power is defined as the worker’s ability to earn income as a result of labor. RCW 51.32.090 provides for compensation to a worker for loss of earning power when the worker’s earning capacity has decreased as a result of the industrial injury or occupational disease. Refers to a partial loss; a total loss would be compensated as Time Loss. 

 

M 

 

Maximum Medical Improvement (MMI): This is a term of art used throughout the US to describe the condition in which no further healing or recovery from an injury is likely through continued treatment. In Washington, this is referred to legally as “fixed and stable.” 

 

Medical Aid Fund: Provides for medical care and vocational rehabilitation counselor services for injured workers. Half the premiums for the Medical Aid Fund are paid by the workers and half are paid by the employers.

 

Medical Only Claim: A workers’ compensation claim that involves only medical treatment expense, no allowed (compensable) lost time.

 

My Secure L&I: An online registration portal that provides stakeholders with secure access to information at L&I and allows them to take advantage of L&I’s secure online services.

 

N

 

National Academy of Social Insurance (NASI): A nonprofit member organization made up of specialists on social insurance. Its stated mission is to advance solutions to challenges facing the nation by increasing public understanding of how social insurance contributes to economic security.

 

National Council on Workers' Compensation Insurance (NCCI): An insurance funded trade organization that gathers data, analyzes trends, and prepares insurance rating rules, and files loss cost recommendations with states in which it is licensed.

 

O

 

Office of the Self-Insured Ombuds: A state agency function designed to assist workers of self-insured employers with workers’ compensation issues. It is housed within L&I but is independent of the Insurance Services Division, which is the L&I division that is responsible for management workers’ compensation claims. The Ombuds is appointed by the Governor.  

 

Order: A writing that formalizes an L&I claim manager decision. An order carries the right to protest or appeal.

 

ORION: The web-based information system at L&I used by claim managers to access imaged documents and other information involved in managing claims. Some updates from the LINIIS system are automatically posted to ORION.

 

P

 

Pension: The term used in Washington to describe Total and Permanent Disability. Those who qualify receive a monthly payment for their lifetime, regardless of the age at injury. Survivor’s benefits are possible. The benefit level is adjusted annual for cost of living increases. Eligibility is determined based upon whether the worker is employable in gainful employment. 

 

Pension Adjudicator: A senior claim manager who serves on a team dedicated to review and management of pension claims.

 

Permanent Partial Disability (PPD): This is a benefit to compensate for the permanent loss, or significant limitation, of a body part or system due to a work injury. It is usually awarded after the worker has reached fixed and stable condition and a doctor has rated the permanent impairment to the injured worker. 

 

Project Help: Program funded by L&I to offer one-on-one assistance regarding Washington workers’ compensation claims. Staff assist workers by answering questions or interpreting correspondence from L&I. Program is operating under contract with the State Labor Council.

 

Protest: A formal complaint to L&I regarding an L&I decision made in the course of managing a claim. The claim manager who made the decision under protest initiates and manages an internal review of the decision upon receipt of a protest.

 

R

 

Re-assumption: A decision by L&I to review an L&I decision following the filing of an appeal with the BIIA. After the filing of an appeal, the BIIA will offer L&I the opportunity to re-assume jurisdiction over a claim for the purposes of reviewing the decision prior to formal processing of the appeal. If re-assumed, the appeal will be dismissed, and the dispute is handled as if a protest, subsequent to which, if still un-resolved, litigants may choose to pursue appeal.

 

Report of Accident (ROA): The first official report of the claim for compensation sent to L&I. Usually provided by the physician that treated the injured worker, but can also be initiated by the injured worker. The report has certain mandatory medical findings that must be supplied by the physician to determine if the claim is valid.

 

Retraining Plan: In the context of vocational and rehabilitation services, a retraining plan is done by a private counselor at the selection of the claim manager. It is supposed to involve the injured worker and consider the aptitudes, work history, and personal limitations of the client. By law the plan must be developed in 90 days, unless delays are authorized by L&I.

 

Retro Program: A program administered by L&I, available to Washington employers who maintain insurance policies with the State Fund. The program involves a mechanism whereby participants retain a specified targeted level of risk of workers’ compensation related losses. If actual losses end up below the specified target then L&I refunds a portion of premium; if losses exceed the target, then the participant is assessed additional premium. Employers may participate as a member of a Retro Group or as an Individual Retro Employer.

 

Retro Group: A group of employers with certain shared characteristics that self-organizes and participates in the L&I Retro Program. Premiums are distributed among the group, as are any refunds or assessments; refunds and assessments are distributed or charged to individual group members according to the group charter agreement. A Retro Group will employ a Retro Group Manager to manage its interaction with L&I and the claims of its members. Retro Group. Members of a Retro Group elect to have group retrospective premium calculated, based on the combined premium and incurred loss data of participants. Members must comply with eligibility requirements for the group association they seek to join.

 

Return to Work (RTW): The return to employment by a worker following a workers’ compensation injury. Refers to either returning to the pre-injury employer or with a new employer. One of the primary goals of L&I’s strategic plan is to “held injured workers heal and return to work.”

 

S

 

State Fund: The workers’ compensation insurance pool that is funded by premiums, part of which are paid by employers and part by employees, and that pays losses of claims managed by the Washington Department of Labor and Industries.

 

Self-Insured Employer: An employer that applies for and is authorized by L&I to pay for its workers’ compensation claims directly. A self-insured employer is required to post security, at a level determined by L&I, to ensure that it is able to cover its losses. Self-insured employers often utilize third-party administrators, or TPAs, to manage claims.

 

Stay at Work Fund: Provides partial reimbursement for wages, training, and equipment to employers who provide light duty or transitional work for injured workers. Half the premiums for the Stay at Work Fund are paid by the workers and half are paid by the employers.

 

Stay at Work Program: Stay at Work is a financial incentive that encourages employers to bring their injured workers quickly and safely back to light-duty or transitional work by reimbursing them for some of their costs. Eligible employers can be reimbursed for: 50% of the base wages they pay to the injured worker; and some of the cost of training, tools or clothing the worker needs to do the light-duty or transitional work.

 

Structured Intensive Multidisciplinary Program (SIMP): a chronic pain management program with the following 4 components:

  • Structured means care is delivered through regular scheduled modules of assessment, education, treatment, and follow up evaluation where workers interact directly with licensed healthcare practitioners. Workers follow a treatment plan designed specifically to meet their needs, and

  • Intensive means the Treatment Phase is delivered on a daily basis, 6 to 8 hours per day, 5 days per week, for up to 4 consecutive weeks. Slight variations can be allowed if necessary to meet the worker’s needs, and

  • Multidisciplinary (interdisciplinary) means that structured care is delivered and directed by licensed healthcare professionals with expertise in pain management in at least the areas of medicine, psychology, and physical therapy or occupational therapy. The SIMP may add vocational, nursing, and additional health services depending on the worker’s needs and covered benefits, and

  • Program means an interdisciplinary pain rehabilitation program that provides outcome focused, coordinated, goal oriented team services. Care coordination is included within and across each service area. The program benefits workers who have impairments associated with pain that impact their participation in daily activities and their ability to work. This program measures and improves the functioning of persons with pain and encourages their appropriate use of healthcare systems and services.

 

Supplemental Pension Fund: The Supplemental Pension Fund premiums cover the annual cost of living increases in pension and time-loss benefits that are paid during the rating year. The same rate is paid by all risk classifications and is also paid by self-insured employers and workers. Half the premiums are paid by the workers and half are paid by the employers.

 

T

 

Third-Party Administrator (TPA): In Washington, a business organized to provide workers’ compensation claims management services to self-insured employers, or in some cases to insured employers that want professional assistance to improve L&I handling of their claims.

 

Time Loss (TL) Claim: A claim involving an indemnity payment for lost wages during recovery from an injury or disease. It is based on a formula that considers previous earnings and some employer provided benefits, and has a cap on maximum weekly benefits. Atypically, the Washington formula also considers the number of dependents. In many jurisdictions, and in most comparative data studies, “Temporary Total Disability,” abbreviated as “TTD,” is used instead of “TL.” These terms are generally interchangeable.

 

Total and Permanent Disability (TPD): Another term for "pension." 

 

V

 

Vocational Improvement Pilot (VIP): A comprehensive set of reforms for vocational retraining that was first implemented in 2008 as a pilot program, and has since been made (VIP) permanent. VIP set goals for improving the efficiency and effectiveness of retraining and return to work.

 

Vocational Rehabilitation Counselor (VRC): A Vocational Rehabilitation Counselor is a person with training, experience, and/or certification (WAC296-19A-210) to identify return to work options. Most VRCs are privately employed. L&I contracts with VRC to perform well defined services related to work injuries and claims for benefits. VRC have reporting requirements to the CM that hired them.

 

W

 

Workers' Compensation Advisory Committee (WCAC): Created by the Washington State Legislature in 1971 (RCW 51.04.110). The WCAC members advise and serve as a sounding board for the Director of L&I and the Assistant Director for Insurance Services on matters pertaining to the (WCAC) state's workers' compensation system. Members include representatives from business, organized labor, self-insured employers and the Board of Industrial Insurance Appeals (BIIA). The WCAC meets at least every quarter. Meeting topics include: Budget issues; Policy changes; New programs; and Insurance rates.

 

Workers' Compensation Research Council (WCRI): A not-for-profit research organization providing information about public policy issues involving workers' compensation systems. Organized in late 1983, the Institute provides information obtained through studies and data collection efforts.