Workers' comp and the 'first aid' controversy. (Health Care Industry Spotlight).

As an occupational medicine physician I am frequently asked by the employer of the injured worker, "can this be a first aid case?" This question is asked because employers want to control as much of their minor medical expenses as possible by paying for these claims in order to reduce their loss experience modification. Historically this would have prevented a rise in insurance premium rates. However, the experience rating formula calculation has been changed and frequency of claims may now have a diminished effect on premiums within certain insurance companies. Therefore, employers should discuss this issue with their insurers to determine if paying for these claims is still cost-effective.

A first aid injury is defined in the Labor Code [section] 5401 as any one-time treatment of minor scratches, cuts, burns, splinters, or other minor industrial injury. 'Minor industrial injury shall not include serious exposure to a hazardous substance as defined in subdivision (i) of section 6302.' The California Code of Regulations [section] 14311 states that any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require medical treatment, may be considered first aid even though provided by a physician, nurse or other health care professional. All other injuries are considered Medical Treatment and are recordable per OSHA guidelines, therefore, requiring the employer to provide the injured worker with an Employee's Claim Form and submit an Employer's Report of Occupational Injury on form 5020 Rev. 6, or by computer media. The physician must submit a Doctor's First Report of Injury on form 5021 Rev. 4, o r on computer media, on every case, including first aid injuries within five working days after initial examination, with the employer, if self-insured, or to the employer's insurer, as the case may be.

Although the many examples of first aid provided by OSHA guidelines are beyond the scope of this article, the following cannot be considered first aid: prescription medications, other than one initial dose, fractures noted on x-rays, suturing of wounds, surgical removal of foreign bodies from the skin or eyes (other than by means of irrigation or use of swabs, tweezers or other simple means), injections (other than tetanus shots), and restricted work status.

The definitions of first aid cases, although seemingly quite clear, can be quite confusing and controversial. Both employers and physicians have erroneously labeled some occupational injuries as fist aid only to find that ongoing care beyond the follow-up visit was needed, thereby placing them in a non-compliance situation with regard to the labor code reporting requirements. This may have been done intentionally by employers wanting to limit their frequency of reporting, or by physicians wishing to remain in favor with their employer-clients in order to continue receiving referrals for treatment of occupational injuries. On the other hand it may have been as a result of confusion due to an ambiguous clinical situation on the part of either party. Nevertheless, such practices could be perceived as insurance fraud by insurers and associated enforcement agencies.

The best advice to be offered to employers and physicians with questions and concerns regarding fist aid cases and reporting requirements is to discuss these issues with a qualified occupational health care physician or visit one of the OSHA websites.

Barry S. Rosenblum, D.O. is Medical Director of the Healthline Medical Group in Van Nuys. He can be reached at [e-mail]