FECA PT3 PR 700

User Manual: PR 700

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FECA-PT3 Printed: 08/02/2011

PART 3 - MEDICAL

(Issued 09/95; Trans. No. 95-39)

LIST OF CHAPTERS

3-0100 Overview

3-0200 Functions of the Medical Unit

3-0201 Staff Nurse Services

3-0202 Contract Field Nurse Certification

3-0300 Authorizing Examination and Treatment

3-0400 Medical Services and Supplies

3-0500 OWCP Directed Medical Examinations

3-0600 Requirements for Medical Reports

3-0700 Schedule Awards

3-0800 Exclusion of Medical Providers

3-0900 Administrative Matters

CHAPTER 3-0100 OVERVIEW

TABLE OF CONTENTS

Paragraph and Subject Date Trans. No.

Table of Contents 09/95 95-39

1. Purpose 10/90 91-02

2. Benefits 10/90 91-02

3. Definitions 10/90 91-02

04/93 93-24

4. Subjects Covered 09/95 95-39

3-0100-1 Purpose

1. Purpose. This part of the procedure manual describes for both physicians and

claims personnel the procedures for administering the medical care program under

the Federal Employees' Compensation Act (FECA). Examination of case files and

authorization of medical care are conducted through the cooperative efforts of the

Medical Unit and the Claims Units within each district office.

3-0100-2 Benefits

2. Benefits. The FECA provides the following benefits for Federal employees:

a. Medical Care. Services prescribed or recommended by a qualified

physician which are likely to cure, give relief, reduce the degree or the period

of disability, or aid in lessening the amount of monthly compensation may be

authorized. These services include surgery and hospitalization as well as

appliances and supplies.

b. Disability Benefits. Compensation is paid for lost wages resulting from

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the employment-related injury, disease or illness.

(1) Total Disability. A claimant is paid compensation for total

disability when the employee is medically unable to perform gainful

employment due to employment- related injury, disease or illness.

The loss of use of both hands, both arms, both feet or both legs, or

the loss of sight of both eyes, is considered prima facie evidence of

permanent total disability (section 8105 (b) of FECA), though

claimants with these disabilities are sometimes still able to work.

(2) Partial Disability. Reduced benefits are paid when the

employee is not totally disabled but is capable of performing duties

which are compatible with the medically imposed work limitations

resulting from the injury, disease, or illness. The amount of

compensation paid commensurate with the employee's loss of wage-

earning capacity (sections 8106 and 8115 of FECA).

c. Schedule Award. Compensation for permanent impairment of certain

members or functions of the body may be paid regardless of the employee's

ability to work. A schedule award is payable when the condition has reached

maximum medical improvement. The AMA Guides to the Evaluation of

Permanent Impairment form the basis for awards. Awards are also payable

for disfigurement of the face, head or neck which is likely to handicap the

claimant in maintaining or securing employment (section 8107 of the FECA).

d. Vocational Rehabilitation. Vocational rehabilitation services are

provided when an injured employee is unable to return to his previous work

(section 8104 of FECA).

e. Death Benefits. A range of benefits for the dependents of an

employee whose death was employment-related is provided (sections 8133

and 8134 of the FECA).

f. Miscellaneous Benefits. Other benefits include reimbursement for

transportation costs incurred in obtaining medical treatment or rehabilitation

services. Nursing and other paramedical services are included when they are

likely to be beneficial, and an attendant's allowance is payable in addition to

compensation to severely disabled claimants.

3-0100-3 Definitions

3. Definitions. By statute, the term "physician" includes surgeons, podiatrists,

dentists, clinical psychologists, optometrists, osteopathic practitioners, and

chiropractors within the scope of their practice as defined by state law.

a. Psychologists. OWCP has accepted the American Psychological

Association's definition of a clinical psychologist as an individual who:

(1) Is licensed or certified as a psychologist at the independent

practice level of psychology by the state in which he or she practices,

and

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(2) Either possesses a doctoral degree in psychology from an

educational institution accredited by an organization recognized by the

Council on Post-Secondary Accreditation or is listed in a national

of the Department of Labor deems appropriate, and

(3) Possesses two years of supervised experience in health service,

at least one year of which is post degree.

b. Chiropractors. These practitioners are defined as "physicians" only to

the extent that their reimbursable services are limited to treatment consisting

of manual manipulation of the spine to correct a subluxation as

demonstrated by X-ray to exist. A chiropractor has the right to interpret his

or her own X-rays to determine whether they support the diagnosis of

subluxation and to determine any period of disability resulting from that

condition. OWCP defines subluxation as an incomplete dislocation, off-

centering, misalignment, fixation or abnormal spacing of the vertebrae.

c. Physicians' Assistants. These practitioners, who are not physicians

under the Act, receive academic training and clinical experience and may be

certified by the National Commission on the Certification of Physician's

Assistants. A report prepared by a physician's assistant which is

countersigned by a physician should be accepted as medical evidence.

d. Religious Practitioners. The Christian Science Church permits

treatment of its members only by its own practitioners, though it has no

objection to periodic examinations to determine entitlement to compensation

and to assess whether maximum medical improvement has been reached.

The FECA does not authorize treatment by nonmedical practitioners of the

healing arts, such as psychic healers or faith healers, although they may be

permitted at the claimant's expense.

3-0100-4 Subjects Covered

4. Subjects Covered. The roles of the District Medical Director, District Medical

Adviser, Medical Management Assistant, and Staff Nurse are discussed briefly in

Chapter 3-200, and the Staff Nurse's work is addressed more fully in Chapter 3-201.

Chapter 3-202 addresses certification procedures for contract nurses. The

procedures for authorizing treatment and the provision of supplies are described in

Chapter 3-300, while treatments and supplies which may be authorized under the

FECA are detailed in Chapter 3-400. The process of obtaining medical evaluations is

described in Chapter 3-500, and requirements for medical reports are detailed in

Chapter 3-600. Schedule award determinations are considered in Chapter 3-700.

Procedures for excluding a medical provider are detailed in Chapter 3-800, and

administrative matters are considered in Chapter 3-900.

CHAPTER 3-0200 - FUNCTIONS OF THE

MEDICAL UNIT

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TABLE OF CONTENTS

Paragraph Subject Date Trans. No.

Table of Contents 05/94 94-24

1. Purpose 04/93 93-24

2. Structure of the Medical Unit 04/93 93-24

3. District Medical Director (DMD) 04/93 93-24

10/90 91-02

4. District Medical Adviser (DMA) 10/90 91-02

5. Medical Management Assistant (MMA) 10/90 91-02

04/93 93-24

6. Staff Nurse 04/93 93-24

3-0200-1 Purpose

1. Purpose. This chapter describes the roles and responsibilities of OWCP

medical staff, which usually includes a senior Federally employed physician as

District Medical Director, (DMD), one or more District Medical Advisers (DMA), one or

more Medical Management Assistant(s) (MMA), and a Staff Nurse.

3-0200-2 Structure of the Medical Unit

2. Structure of the Medical Unit. The responsibility for oversight of the Office's

medical benefits program is vested in the DMD, who works under the medical

guidance of the OWCP National Office Medical Director and the administrative

supervision of the Regional Director (RD) or the District Director (DD). A district

office may have one or more DMAs (usually contract employees), and the functions

of each office's Medical Unit are aided by one or more MMAs. The Staff Nurse

coordinates the work of the Field Nurses who act on behalf of each district office in

the case management process.

3-0200-3 District Medical Director (DMD)

3. District Medical Director (DMD). The functions of the DMD include the

following:

a. Establishes liaison with regional professional societies State health

departments, and individual providers within the district office's jurisdiction.

The DMD can familiarize the medical community with the nature of the

program and its needs and objectives. Specific areas which may be

addressed include types of medical reports and their use within the program;

requirements for content and quality of medical reports and the impact of

these factors on the length of the adjudicatory process as well as continued

use of a particular consultant; the Office's commitment to the rehabilitation of

the employee and the resources available to this end; and new policies and

procedures as warranted.

Such meetings allow the DMD to transmit concerns and suggestions from the

medical community to district office managers. These contacts may be

arranged by the DMD alone, or by the DMD in conjunction with district office

management, and it may take the form of contacts with local medical

societies and other groups of physicians such as the medical staff of local

hospitals, and providers in group practices. The DMD may also obtain from

district office files the names of physicians who have served as consultants in

cases involving a particular disease, such as asbestosis, and sponsor

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meetings to discuss changes in diagnosis and treatment as well as

administrative matters.

b. Visits with major employing agencies within the district office's

jurisdiction. The DMD can also perform a useful function by encouraging

employing agency personnel to conduct limited outreach efforts with

physicians in their respective geographic areas. Such efforts may include

tours of the employing agency and demonstrations of the types of light duty

which may be available to partially disabled workers, so that physicians will

be more aware of options other than continuing the claimant on total

disability.

c. Identifies and evaluates the credentials of physicians willing to serve

as consultants (DMAs) to manage workloads. (The method of selecting a

consultant for this function is identical to the procedure for obtaining second

opinion examinations, which is described in Chapter 3-900).

d. Establishes and administers a network of medical specialists (second

opinion specialists) and DMAs who provide the Office with medical opinions

(see Chapter 3-900).

e. Provides training and guidance to Claims Examiners (CEs) and other

district office staff regarding medical issues. The DMD may properly advise

CEs concerning the tone and content of letters sent to members of the

medical community. He or she may provide formal and/or informal training

on common conditions and medical treatment issues to the district office

staff. The DMD also has an advisory role to bill pay staff within the district

office.

f. Identifies and reports medical trends to district office management and

the OWCP Medical Director. The DMD advises the DD or RD concerning

customary ranges of fees for various services in the area and advises the RD

concerning exclusion of medical providers. The DMD will monitor the

performance of referral specialists and advise the DD or RD of physicians

whose reports are consistently incomplete, unreliable, or late.

g. Provides professional opinions and technical advice in connection with

the adjudication and management of complex claims.

The DMD does not perform medical examinations or functions of a clinical nature

except for participating in evaluation of claimants who seek an award for

disfigurement of the face, head or neck (see Chapter 3-700). Moreover, while the

DMD does not act in a supervisory capacity per se, he or she does have

administrative oversight with respect to the medical functions of the district office.

3-0200-4 District Medical Adviser (DMA)

4. District Medical Adviser (DMA). The functions of the DMA (and the DMD

insofar as he or she performs medical evaluations of case files) include interpretation

of medical reports; rendering medical evaluations in his or her own right; and

providing guidance or instruction to claims staff regarding general medical issues

which are in compensation claims.

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a. Interpreting Medical Reports. The CE seeks the interpretive function of

the DMA where the medical evidence is complete and sufficient prior to such

review. In this form of review, the DMA may determine the percentage of

permanent partial impairment, evaluate test results, or "translate" technical

language. The DMA may also be asked to review reports from referee

specialists where a schedule award is at issue (see Chapter 3-600).

b. Rendering Medical Evaluations. The CE seeks advice from the DMA to

proceed with developing and weighing the medical evidence where the

report from the attending physician, second opinion or referee

specialist is not clear and well rationalized, and the DMA provides written

opinions on medical questions posed by members of the claims staff.

In this capacity, the DMA may advise whether a claimant's condition is

employment-related, whether the effects of an accepted condition continue,

and whether the claimant is receiving appropriate medical care, including

whether recommended procedures, appliances or treatment are useful or

necessary. The DMA may also be asked to comment on proper development

of the medical evidence where an unusual condition is under consideration.

The Employees' Compensation Appeals Board has addressed the role of the DMA in

its decision in the case of Carlton L. Owens, 36 ECAB 608:

The role of the Office medical adviser is to act as a consultant in reviewing

cases under the Federal Employees' Compensation Act. Claims examiners

make use of the services of medical advisers in adjudicating the issues of

causal relationship, extent of disability, degree of permanent impairment, and

suitability of work. The Office medical adviser's role is not to act in an

adjudicatory capacity or address legal issues in the case, and the Office

should carefully observe the distinction between adjudicatory questions which

are not appropriate and medical questions which are appropriate.

c. Monitoring Medical Care. While the DMA does not routinely monitor

cases to ensure adequacy of medical care, he or she is expected to recognize

issues regarding the quality of care arising in the cases he or she evaluates.

CEs may also identify cases where the propriety of medical care is in question

and should refer them to the DMA for action or advice. Issues may include:

(1) Appropriateness/Usefulness of Treatment. The criteria used in assessing the

suitability of medical care as well as Office policies regarding specific treatments and

appliances which may be authorized are discussed in Chapter 3-400.

(2) Length of Treatment. The duration or frequency of treatment appears

excessive for the condition or incompatible with the norm for the medical

community.

(3) Transfer of Medical Care. Claimants not infrequently request changes in

attending physician, but the Office seldom initiates this action. Transfers of care

should be handled according to the claimant's medical needs with due regard for

medical protocol.

A case sent to the DMA for evaluation of another matter may reveal

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issues pertaining to the suitability of medical care, and the DMA is

expected to use his or her medical expertise to recognize such

problems and bring them to the CE's attention.

3-0200-5 Medical Management Assistant (MMA)

5. Medical Management Assistant (MMA). The MMA's function is to assist the

DMD in the administration of the Medical Unit and to perform associated support

functions, which include:

a. Screening. The MMA examines incoming case files to ensure that all

necessary information is present, including a list of questions and Statement

of Accepted Facts.

b. Scheduling. The MMA schedules appointments for second opinion and

referee examinations in accordance with the Office's procurement and

rotation policies and the specific requirements of each type of examination.

c. Advising of Arrangements. The MMA prepares letters to claimants and

physicians once such examinations have been scheduled and ensure that all

necessary information and material is provided to each party.

d. Record-Keeping. The MMA maintains records concerning utilization of

physicians in each category as well as logs pertaining to prompt payment of

bills; keep records of cases out of the office and contact physicians when

reports and cases are overdue.

e. Documenting Exclusion Data. The MMA maintains information

concerning exclusion of medical providers and ensures that documentation of

alleged infractions is routed to the correct parties within the district office.

f. Keying. The MMA may key outgoing cases to other parts of the district

office. The MMA ensures that location printouts reflect only the cases actually

present in the medical unit, and initiates searches for any other cases.

3-0200-6 Staff Nurse

6. Staff Nurse. The OWCP Staff Nurse is responsible for coordinating the nurse

intervention process in the district office, which in turn is directed toward managing

disability claims to facilitate recovery and, if possible, return to work. This function

includes:

a. Selecting cases for intervention, in some district offices, and assigning

them to Field Nurses with the CEs' concurrence.

b. Acting as liaison between the Field Nurses and CEs. This function

includes answering questions from both parties, interpreting OWCP practices

to the Field Nurses, and helping the CEs to understand the nurses' role in

managing cases.

c. Procuring and selecting enough field Nurses to provide high quality

services to OWCP claimants, and managing and monitoring their activities on

a case by case basis as well as cumulatively.

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d. Training Field Nurses on intervention procedures and formal and

informal training of CEs and OWCP staff on these procedures and other

medical topics as warranted in the particular office.

e. Performing other liaison activities such as outreach to the medical

community and scheduling certain second opinion and impartial examinations

to ensure that these are performed in a timely fashion and the resulting

reports address CEs' concerns fully.

See PM 3-201 for a fuller discussion of the Staff Nurse's duties.

CHAPTER 3-0201 - STAFF NURSE SERVICES

TABLE OF CONTENTS

Paragraph and Subject Date Trans.No.

Table of Contents 11/98 99-06

1. Purpose and Scope 04/93 93-29

2. Definition 04/93 93-29

3. Nurses' Roles in the District Offices 04/93 93-29

4. Types of Nurse Interventions 04/93 93-29

5. Phases in the Intervention Process 04/93 93-29

6. Preliminary Steps 04/93 93-29

09/95 95-39

7. Performing Interventions 04/93 93-29

08/94 94-34

10/95 96-04

09/96 96-15

8. Extensions and Interruptions of Nurse Services 09/96 96-15

9. Communications Between the CE and RN 09/96 96-15

10. Tracking the Nurse Intervention 09/96 96-15

11. Liaison Activities 09/96 96-15

12. Supervising Field Nurses 09/96 96-15

13. Other Medical Management Functions of the

Staff Nurse 09/96 96-15

14. Billing by the Field Nurse 09/96 96-15

15. Functional Capacity Evaluations (FCEs) 11/98 99-06

Exhibits

1. Initial Evaluation of Claimant 12/94 95-04

2. Progress Record 12/94 95-04

3. Sample Advertisement for Nurse Services 12/94 95-04

4. General Selection Guidelines 12/94 95-04

5. Suggested Training Topics 12/94 95-04

6. Sample Letter Authorizing Nurse Services 12/94 95-04

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7. Prompt Pay Authorization (Link to Image) 12/94 95-04

3-0201-1 Purpose and Scope

1. Purpose and Scope. The role of the Staff Nurse in the FEC district offices is to

aid in managing disability cases. The Staff Nurse's role and functions in this process

are the subject of this chapter. Included in the discussion will be specific nursing

functions, intervention and liaison activities which will assist the Claims Examiner

(CE) in managing cases.

3-0201-2 Definition

2. Definition. In its broadest scope, case management is a comprehensive

approach to minimize the length and perhaps the extent of disability in some

compensation cases. In this process, nurses will play a vital role by participating in

the early, aggressive medical management of cases. The primary focus of the

nurses' activities will be to encourage recovery and the return to work through direct

interventions with the claimants, treating physicians, and employing agencies.

3-0201-3 Nurses' Roles in the District Offices

3. Nurses' Roles in the District Offices. Nurses involved in case management

may be OWCP staff members or private sector professionals working with the

program on a contractual basis. While the latter (Field Nurse) can perform only the

actual interventions, the OWCP Staff Nurse may coordinate nurse intervention as

well as actually intervening in cases.

a. The Nurse Intervenor Role. The Staff or Field Nurse functioning in this

role will be working closely with OWCP office staff and claimants, physicians in

the community, and employing agencies to assist in the return to work effort.

For clarity, a nurse acting in this role will be designated as Field Nurse

throughout this chapter.

b. The Nurse Coordinator Role. The OWCP Staff Nurse acting in this

capacity is responsible for coordinating the nurse intervention process in the

district office. This function includes:

(1) Selecting cases and assigning them to the Field Nurse(s),

(2) Managing Field Nurses and monitoring their activities on a case

by case basis as well as cumulatively,

(3) Acting as liaison between the Field Nurses and CEs,

(4) Procuring and selecting enough field Nurses to provide high

quality services to OWCP claimants,

(5) Training Field Nurses on intervention procedures and formal

and informal training of CEs and OWCP staff on these procedures and

other medical topics as warranted in the particular office, and

(6) Performing other liaison activities such as outreach to the

medical community and scheduling certain second opinion and

impartial examinations to ensure that these are performed in a timely

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fashion and the resulting reports address CEs' concerns fully.

3-0201-4 Types of Nurse Intervention

4. Types of Nurse Intervention. The nurse intervention process can be classified

according to the degree of interaction: limited, moderate or intensive. The Staff

Nurse determines the appropriate type of intervention based on the diagnosis, the

severity of the injury or illness and demographic considerations.

a. Limited intervention consists of telephone interaction only. This

method provides the ability to reach a greater number of claimants and is

most effective in uncomplicated sprains and strains with a delayed return to

work date. Phone contact is initiated with the claimant and details of the

injury are discussed. In the follow-up phone calls, the nurse reinforces the

treatment regimes of the treating physician and formulates return to work

plans with the claimant and treating physician.

While phone contacts are not restricted as to frequency, the nurse must keep

in mind that too many phone contacts may inadvertently reinforce patients

who exhibit high levels of pain and illness behavior. If contacts are set up on

an as-needed basis, patients having the most difficulty will likely get the most

contact. Intervention, to be effective, should be completed within four

months.

b. Moderate intervention combines both phone calls and face-to-face

interaction. This type of intervention begins with phone contact but as the

intervention continues, evolving circumstances may warrant face to face

contact.

For example, if in the course of phone intervention, it becomes apparent that

the claimant's physician is planning surgery, a re-operative/post-operative

visit by the nurse will assist to reinforce return to work goals. Typically, these

interventions will not exceed four months' duration. However, there will be

cases (complicated post-operative period) requiring an extension of the

nurse's time, and the CE must provide authorization for this extension.

c. Intensive intervention is reserved for catastrophic cases such as head

or spinal cord injuries with extensive functional deficits where the medical

recovery is expected to extend over long or indefinite periods of time. In

these cases, the immediate intervention is directed at the claimant's needs

during the acute phase of injury (coordinating hospital care with the variety of

specialists in the case) and continues until stabilization (e.g., placement in a

rehabilitation facility or home with modifications) has been achieved and

vocational rehabilitation can be recommended.

Usually vocational rehabilitation services do not begin until nurse services

end, but in these cases it may be important to begin vocational counseling

during the period of nurse intervention. The Field Nurse assigned to the case

is responsible for identifying cases that may benefit from vocational services.

He or she should communicate this recommendation to the CE involved in the

case.

3-0201-5 Phases in the Intervention Process

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5. Phases in the Intervention Process. The intervention process, regardless of

the type, can be divided into four stages as briefly described below. Throughout

each phase, the nurse monitors the quality of medical care rendered to the claimant

and communicates frequently with the CE regarding the claimant's progress.

a. Identification Phase. The Staff Nurse, CE or other staff identifies cases for

intervention according to standard criteria. Communication is initiated with all

parties: claimants, treating physicians and employing agencies.

b. Monitoring Phase. The Field Nurse reviews the physician's overall

treatment plan and identifies areas needing CE attention (prior authorization

for surgery, prolonged bed rest, etc.) As necessary, the nurse discusses

issues with the parties concerned and participates in updating or modifying

the treatment plan to fit the claimant's changing health status.

c. Assessment Phase. The Field Nurse determines whether return to work

is possible and whether return to work plans are available and feasible.

Collaborates with all parties (CE, physician, agency, claimant) to implement

the return to work.

d. Discharge Planning Phase. The Staff Nurse assesses the outcome of

the intervention and, as necessary, follows up in the case to ensure continuity

in its management. If the claimant has returned to work, the Field Nurse will

provide follow-up for 60 days. In cases where the nurse intervention period

has expired and the return to work has not occurred, the Staff Nurse will refer

the case to the CE with appropriate recommendations such as referral for

vocational rehabilitation services, second opinion, etc.

3-0201-6 Preliminary Steps

6. Preliminary Steps. Nurse intervention early during the period of disability is

one of the major components of the quality case management procedures. This

section details all the important aspects and steps in this process.

a. Criteria for Case Selection. Cases which have been traditionally

associated with poor outcomes in terms of return to work, cases where the

outcome is uncertain, and cases where specific medical issues need to be

clarified, should be referred for nurse intervention.

(1) Traumatic Injury Cases. Although the ideal time for nurse

intervention is from 45-90 days after the day of injury, the CE may

refer traumatic injury cases for nurse intervention regardless of the

time elapsed since the injury if:

(a) The medical evidence does not state a return to work

date;

(b) The return to work date is unrealistic (i.e., not in

keeping with the magnitude of the original injury);

medical reasons;

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(d) The claimant is partially disabled but the file does not

contain a description of work limitations;

(e) The CE requires additional medical information for the

initial or continuing authorization of unusual and/or prolonged

services such as intensive home nursing, housing modifications

and extensive surgery or physical therapy.

(2) Occupational Illness Cases. These cases ordinarily require

more than 90 days to adjudicate, thus placing them outside the

optimum time frame for nurse intervention. Therefore they will not

routinely be referred for continuing nurse intervention, though they

may be referred for advice and assistance with particular issues [see

paragraph a(1)(e) above]. Referral for vocational rehabilitation

services will likely be more appropriate in most occupational illness

cases.

b. Sources of Cases for Nurse Intervention.

(1) CE Referrals. CEs are tasked with identifying cases that meet the criteria

indicated above. The CEs will identify a significant number of these cases at the time

of the authorization for the first compensation payment (excluding most leave buy-

backs and schedule awards).

(2) Automated Reports. Staff Nurses may identify cases that meet

the above criteria using automated reports of CA-7 payments or other

reports containing similar information.

(3) Other Sources. In some instances, employing agencies,

Vocational Rehabilitation Specialists, District Medical Directors or

Advisors and others can identify cases which may benefit from nurse

services. All cases referred in this fashion should be discussed with

the CE before nurse intervention is offered to the claimant since the

final authority to intervene with the claimant remains a prerogative of

the CE.

c. Work/No Work Call. The initial interaction with claimants occurs

during the initial telephone call. The purpose of this call is to ascertain the

work status of the claimant and to inform those claimants who meet the

above indicated criteria of the intended nurse intervention in his or her case.

The CE may make this call. However, in those offices where the Staff Nurse

identifies potentially eligible cases from automated reports, this call will be

the responsibility of the OWCP Staff Nurse and he or she should follow the

steps detailed below:

(1) If the claimant has returned to full duty, the nurse notifies the

CE. In most instances, the nurse recommends that further

intervention is not necessary. However, in some cases where the

nurse has reason to believe that the medical condition is unstable or

that the claimant might stop working for other reasons, he or she may

recommend a follow-up call in four weeks to verify that the claimant

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remains at work;

(2) If the claimant has returned to modified and/or part time duty,

the nurse will notify the CE, who will make a decision as to whether

the claimant is to be followed until he or she returns to full-time

employment.

(3) If the claimant has not returned to work but knows when the

return to duty will occur, and the date appears realistic according to

the medical evidence, medical matrix or MEDGUIDE in Folioviews, the

Staff Nurse sets up a call-up for the date specified and calls the

employing agency on that date to find out if the claimant has in fact

returned to work.

(4) If the claimant has not returned to work at the time of the

follow-up call, and either does not state a plan to return to duty or

offers a date inconsistent with the nature and severity of the injury,

the nurse explains the nurse intervention program to the claimant and

attempts to engage the claimant in the program.

(5) Once the call is completed, the nurse notifies the CE of the

result using a Form CA-110 and recommending appropriate action on

Form OWCP-57. Although the intervention program is voluntary,

participation should be strongly encouraged. A claimant who refuses

to be visited may nonetheless allow intervention by telephone. If the

claimant refuses to participate altogether, the nurse ends the

telephone conversation but reports this result to the CE. The nurse

should attempt to secure a medical release from the claimant so that

communication may be initiated with the attending physician.

3-0201-7 Performing Interventions

7. Performing Interventions. The Staff Nurse selects the type of intervention

needed based on the nature and severity of the claimant's condition, the claimant's

geographic location and other factors. At the same time, he or she assigns the case

to a nurse who will actually perform the intervention, and notifies the claimant,

physician, employing agency and the CE.

a. Initial Contacts.

(1) Claimant. The Field Nurse notifies the claimant that they will

be working together through the recovery stage. He or she also

advises the claimant that the treating physician will be made a part of

this collaborative return to work effort.

(2) Treating Physician. The Field Nurse will contact the treating

physician to discuss current and future treatment regimes. Emphasis

is placed on identifying and managing open-ended treatments such as

bed rest and physical therapy, as well as prolonged therapy with pain

medications. As necessary, the nurse may discuss medical issues with

the District Medical Director (DMD) or Advisor (DMA), or may

recommend a second opinion to clarify issues. Ultimately, a return to

work date and concrete work limitations, if needed, will be discussed

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and formulated using Form OWCP-5. As with the claimant, contact is

made initially by phone followed by a confirmation letter.

(3) Employing Agency. The agency will also be contacted by the

Field Nurse. Communication with the agency begins with the

claimant's supervisor or the injury compensation specialist because

this person can furnish important information regarding the job in

question as well as provide some sense of pre-existing interpersonal

issues which may affect the return to work effort.

There are a variety of reasons for the nurse to contact the employing

agency. For example, the nurse notifies the compensation specialist

that one of their employees has been contacted by a nurse, verifies

that the employee has or has not returned to work and, when

applicable, informs the agency that the physician has imposed some

physical limitations for the return to work.

b. Intervention Guidelines. The Field Nurse assigned to the case

performs the intervention. The nurse is responsible for structuring the

intervention in terms of the number, content and the length of contacts with

the claimant and other parties involved. To do so, the nurse should keep in

mind the following guidelines:

(1) The focus of the program is the return to work and the claimant

should be encouraged to participate actively in the treatment plan and

in the resolution of problems which may impact on the recovery effort.

(2) Visits or calls to the claimant should be scheduled on time-

contingent basis rather than as a response to the appearance or

exacerbation of symptoms.

(3) The treating physician should participate in this process by producing a

treatment plan and a projected length of disability which are commensurate with the

claimant's signs and symptoms. If these are not forthcoming or if the physician

refuses to communicate with the nurse, the intervention with the claimant and

employing agency should continue and the MD's refusal to participate should be

communicated to the CE.

(4) Although the Field Nurse is responsible for structuring the number, length,

content and medium (telephone, face-to-face) of the interactions with all

participants, he or she should be aware that the intervention is a finite process. The

intervention is limited to 120 days from the date of referral. In some instances,

where there is substantive evidence that the return to work will occur shortly, the CE

may authorize an additional period of 30 days. Once the period for nurse

intervention has been exhausted, the case is referred to the CE for further action.

c. Intervention Process.

(1) During the first 30 days of intervention, the Field Nurse

determines whether the physician has formulated a treatment plan

and whether the claimant's physical condition is improving. As

necessary, the nurse discusses the formulation or modification of the

FECA-PT3 Printed: 08/02/2011

plan with the physician and the claimant.

As soon as the Field Nurse completes the visits with the claimant and

treating physician, the nurse discusses findings from the visits and the

subsequent plans for follow up action with the CE and the Staff Nurse.

The DMD/DMA may be consulted to ensure that the treatment is

appropriate for the claimant's condition. The CE is made aware of the

need to authorize particular therapies, and that the return to work is

part of the treatment plan.

Once the plan has been formulated, the nurse monitors the physical

progress of the claimant and obtains a return to work date from the

physician, when appropriate. If necessary, the nurse forwards a

OWCP-5 form to the treating physician to define the work restrictions

present and the level of function of the individual. He or she may

discuss the content and the use of the form by OWCP and the

employing agency with the physician.

The nurse may also recommend a second opinion examination, and

with the CE's concurrence, schedule it. However, if the physician

selected is not listed in the Physicians' Directory System, the nurse

should advise the Medical Management Assistant of the physician's

name and address so that this information can be added to the

system.

(2) The nurse works with the employing agency to ensure that the

physical demands of the job are in keeping with any restrictions

imposed by the physician, that there are no significant barriers to the

return to work, and verifies that the return to work occurs on or near

the expected date.

If the return to work is delayed, the Field Nurse communicates this to

the CE and discusses the reasons with all parties concerned as

necessary. The nurse endeavors to re-establish the return to work

emphasis, define a new date and verify that indeed the claimant

returns to work on or near the expected date.

(3) If the return to work date obtained is not within 120 days from

the beginning of the intervention, there is no significant improvement

in the condition of the claimant, or the physician does not produce a

plan, the Staff Nurse ends the intervention and refers the case to the

CE for action. Upon closing the case, the Staff or Field Nurse may

choose to offer specific recommendations such as referral for a second

opinion examination, referral to vocational rehabilitation, or change of

physician.

(4) If the claimant does not return to work on or near the return to

work date, or remains at work less than 60 days, the nurse needs to

determine the underlying reasons and take appropriate action. If a job

adjustment problem (difficulty with the employing agency) is the cause

for the continuing lack of employment or stopping work, the nurse

refers the case to the CE for further action, clearly stating the nature

FECA-PT3 Printed: 08/02/2011

of the problem.

However, if medical problems prevent or cut short the return to work,

the nurse ensures the completion of OWCP-5 by the physician, closes

the intervention and refers the case to the CE. Where the OWCP-5

indicates that the claimant is able, or will be able, to work four hours

or more, the nurse recommends vocational rehabilitation services.

The SN may complete Form OWCP-14 to refer the case for vocational

rehabilitation services, but may not sign the form. The actual referral

remains the CE's responsibility.

If there are no job adjustment or medical problems, but the nurse has

reason to believe that there is non-cooperation on the part of the

claimant, he or she refers the case to CE for further action, presenting

well reasoned justification for his or her opinion.

(5) The CE may decide that a conference call involving the injured

worker, employing agency, Field Nurse, Staff Nurse, CE and Senior CE

will help clarify return to work issues at this point.

d. Case Closure. Nurse intervention can result in various outcomes. If

the intervention has been continuing in nature, the expected result is the

return to work. In most instances, the claimant will return to the pre-injury

position, with or without modifications, or to a light duty arrangement.

Although it is possible that the worker will return to a position outside of his

or her agency during the nurse intervention period, this is not considered

likely. In a number of cases, the return to work will not occur within the

intervention time frames. In both instances, the Staff Nurse will ultimately

close the case from the nurse intervention viewpoint and refer it to the CE for

further action.

(1) To ensure that the adjustment to work is satisfactory, contact is

made with the claimant at least three times during the course of 60

days: on the first day of work, at the end of the first month and at the

end of the 60 days. The Field Nurse will accompany the claimant to

the facility on the first day back on the job. A meeting is held by the

Field Nurse with all concerned (claimant, supervisor, injury

compensation specialist) to confirm an understanding of the basis of

the return to work requirements and to clarify roles.

Should the Field Nurse identify physical or psychological barriers,

deterioration of the medical condition, or any other indication that the

return to work may not be successful, he or she contacts all interested

parties as necessary to resolve the issues within the 60 day time

frame. Monitoring the return to work beyond this period requires CE

approval.

(2) At the end of the 60 days or later if an additional follow-up

period has been approved, the Field Nurse prepares a memorandum to

the Staff Nurse describing the intervention, the type of work accepted

by the claimant, and the date of the placement. In turn, the Staff

Nurse forwards the memorandum to the CE assigned to the case,

FECA-PT3 Printed: 08/02/2011

closes the case from a nursing viewpoint and notes the return to work

in the tracking system.

(3) If the claimant does not return to work during the intervention,

does not remain at work for 60 days, or does not accept the

intervention or cooperate with the nurse, the Field Nurse prepares a

memorandum for the Staff Nurse stating the problem and

recommending closure of the case and a future course of action

(second opinion, change of physician, referral to vocational

rehabilitation, etc.) The Staff Nurse reviews the case and the Field

Nurse reports, closes the case if warranted and advises the CE of the

particular issues of the case and makes appropriate recommendations.

3-0201-8 Extensions and Interruptions of Nurse Services

8. Extensions and Interruptions of Nurse Services. The nurse intervention will

usually last 120 days or less. In catastrophic injury cases, or in cases where the

time and/or dollar limits are exceeded by small amounts and it is clear that the

claimant will return to work within a short period of time, the intervention may

extend beyond this limit if the CE authorizes extensions of time or money.

Extensions of services may also be necessary or desirable in other cases to ensure

that initial return to work is successful, or to help the claimant reach higher levels of

physical capacity, resulting if possible in return to full-time full duty. Extensions may

also be granted if work-related surgery is necessary, or if the injury is a catastrophic

one. Interruptions of services may be desirable because other medical conditions,

either work-related or not, hinder the return to work effort.

a. Extensions.

(1) Initial Return to Work. The CE may approve a 30-day

extension (60 days if requested so that the nurse can provide follow-

up services after return to work). During this period, the Field Nurse

may charge for 60 professional hours or $3,000, whichever comes

first.

(2) Increase in Duty Status. Where the claimant has not returned

to full-time full duty, the FN should stress the need to return to

maximum functioning and work potential. The FN should also continue

to pursue increases in work tolerance limitations and obtain

descriptions of them on Form OWCP-5 at periodic intervals if the

claimant does not return to full-time full duty. These attempts should

be made at approximately two to three week intervals unless the facts

of the case suggest a different plan.

After the 60-day follow-up period ends, the FN may continue to work

toward full-time full duty if the medical evidence shows that such an

outcome is likely. The FN and the Staff Nurse should recommend

additional time in increments of no more than 30 days each, up to a

total of 60 days. The CE must authorize each increment.

(3) Need for Surgery. Below are listed some common surgical

procedures and their usual recovery times. In general, the simple

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procedures should require no more than 8-10 hours of

professional services within the 30-day period. The moderately

complex procedures will require about 12-16 hours of services

within the 60-day period. Since the complex procedures will

typically result in work limitations which may warrant referral for

vocational rehabilitation services, the FN should work toward

stabilizing the claimant's condition and obtaining Form OWCP-5 in

these cases.

TYPE OF SURGERY PROCEDURE EXTENSION

A. Simple, Endoscopies, 30 day extension,

uncomplicated diagnostic for a maximum of

arthroscopy, 150 days

herniorrhaphy

B. Moderately Discectomies 60 day extension,

complex for a maximum of

180 days

C. Very complex Multiple Work with claimant

surgery or surgery fusions, open until stable, then

with serious heart surgery, refer for rehabili-

complications amputation tation services

of limb

b. Interruptions. Return to work may be affected by other medical

conditions (work-related or not), including pregnancy. The CE must approve

interrupted status, which should not continue more than six months. The

status code "NIN" (Nurse Interrupt) should be used.

(1) Concurrent Conditions. For a concurrent non-work-related

condition, or surgery (whether work-related or not), the SN should

determine whether continued FN services will likely be needed within

six months. If so, and the CE concurs, the SN should place the case in

interrupted status until the time of expected recovery. (Interrupted

status, rather than an extension, is appropriate since the claimant

would require little or no active involvement by the FN during this

time.)

(2) FN Actions. During the interruption, the FN should stay in

touch with the claimant to monitor medical issues and maintain a focus

on return to work. If surgery is involved, the FN will typically review

the attending physician's orders with the claimant after surgery and

monitor the claimant's course at home. Also, the FN may discuss the

post-operative plan with the physician by telephone and monitor the

claimant's compliance with these orders. The RN may perform these

services up to five hours per month.

3-0201-9 Communications between the CE and the RN

9. Communications between the CE and the RN. The Field Nurse should inform

the Staff Nurse of the medical progress of the claimant and of issues which may

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hinder the recovery process. As necessary, the nurse should provide thoughtful

recommendations for further action. An initial evaluation after the first contact with

the claimant and the treating physician, and monthly reports thereafter are

expected. For these reports, the nurse uses the Initial Evaluation and Progress

Report Form shown in Exhibits 1 and 2.

Periodically during the intervention and/or at the end of 120 days, the nurse and the

CE or Staff Nurse will confer, either by mail, written memorandum or face-to-face

meeting, to determine the next actions to be taken. The nurse is encouraged to

communicate either with the CE or the Staff Nurse informally as well as by written

report whenever this is necessary during the return to work effort.

3-0201-10 Tracking the Nurse Intervention

10. Tracking the Nurse Intervention. Using the data described below, the Staff

Nurse will be able to analyze various aspects of the program and obtain the basic

statistics necessary to manage the nurse intervention effort. These statistics

include: the numbers of claimants and nurses participating in the intervention

program at any given time, the duration and result of the intervention by case or in a

cumulative fashion in the district office, the rotation of cases among the Field Nurses

and other data.

a. Claimant Data. From the moment a claimant is selected for

intervention, the Staff Nurse or another designated individual must track the

case through the Case Management File (CMF) Tracking System and, in

district offices where it is installed, the Nurse Tracking System (NTS). The

CMF system will include the dates on which the case is referred from the CE

to the Staff Nurse and then to the Field Nurse. A return to work date is also

captured on this system.

b. Field Nurse Data. Information regarding the Field Nurses should also

be maintained, including the name of each nurse, his or her geographic

location, and hourly rate.

3-0201-11 Liaison Activities

11. Liaison Activities. By definition, case management includes the referral of

certain injured workers for second opinion and referee examinations by medical

specialists to ensure the appropriateness of the treatment plan, verify the level of

disability and address other issues related to the medical recovery. To have the

expected impact, these examinations need to occur on a timely basis.

At district office option, the Staff Nurse can assist this process by: actually

scheduling these examinations; reviewing the outgoing CE questions and assessing

the incoming medical reports; interacting with the medical community to acquaint

them with FEC policies and procedures; and enlisting their participation in second

opinions and/or referee examinations. The nurse may also coordinate with the

DMD/DMA in identifying geographical areas requiring outreach activity and in

assisting in the recruiting and retaining of physicians for second opinion referrals.

a. Scheduling Examinations. The use of the Physicians' Directory System

(PDS), an automated directory and tracking mechanism, is mandatory in

scheduling all referee examinations and is optional in the scheduling of

second opinions. Details of this system are found in PM 3-500.7. The nurse

should consult FECA PM 3-500.3 and 3-500.4 for the procedures to be used in

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scheduling second opinion and referee examinations respectively.

The CE determines the need for these examinations and prepares a list of

questions to be answered by the examining physician. He or she should

indicate the type of specialist required. Claimants are to be scheduled as

close to home as is feasible (25 miles is considered reasonable in most urban

areas). In rural areas, and in some urban areas with shortages of physicians,

the claimant will have to travel over 25 miles.

b. Reviewing Outgoing Material. The nurse may review outgoing material

for comprehensiveness of medical data and clarity of the questions posed by

the CE. He or she may recommend changes and discuss issues with CE as

necessary.

c. Tracking Second Opinion and Referee Examinations. Usually, 30 days

is a sufficient time period after the second opinion or referee examination for

the specialist to submit the report. Follow-up phone calls should be made in

cases where no report has been received in the office within 30 days of the

examination. Once received, the report should be reviewed in light of several

factors:

(1) Timeliness is an important consideration in the assessment of

the quality of medical reports. District offices may set their own

criteria in this respect or use six weeks as the standard. Reports that

are not timely should be noted in the NOTES section of the PDS for

monitoring purposes. If the physician is late in submitting the report,

the nurse contacts his or her office and appraises him or her of this

fact and obtains a copy of the report as soon as possible. However, if

no report is forthcoming after a reasonable waiting period, the nurse

notifies the CE for further action.

(2) Content is also crucial. When the report does not address all

questions posed by the CE, or contains equivocal answers, the nurse

so notifies the CE. Upon request of the CE, the nurse may notify the

physician's office of these deficiencies and request clarification or

completion of the report. This second request is also tracked and

reimbursement for the examination may be withheld until clarification

is obtained.

3-0201-12 Supervising Field Nurses

12. Supervising Field Nurses. The Staff Nurse is responsible for procuring,

training and managing Field Nurses who will work directly with OWCP claimants in

the return to work effort.

a. Procurement and Selection. The Staff Nurse develops a structure and

a timetable for the procurement and selection of Field Nurses taking into

account the geographic, volume, and operational requirements of the district

office.

(1) Once the number and location of the Field Nurses needed has

been determined, the Staff Nurse solicits the services of nurses

through advertisements placed in local newspapers, occupational

FECA-PT3 Printed: 08/02/2011

health journals or other nursing newsletters. Advertisements may also

be distributed to local hospitals, universities, nursing schools and

vocational rehabilitation companies. A sample advertisement to

procure contact nurse services is included in Exhibit 3.

(2) Field Nurses must be selected according to standard criteria

which include educational background, licensing, clinical experience,

medical case management, and specific workers' compensation or

occupational health experience. Selection criteria guidelines are

detailed in Exhibit 4.

(3) All applicants should be appraised by the Staff Nurse and any

other staff designated by the district office. The appraisals and the

reasons for the selections must be well documented by the Staff

Nurse.

(4) After the selection of candidates, the Staff Nurse ensures that

each receives and signs a memorandum of agreement. The document

details the various responsibilities of the nurse and the time frames

within which he or she is to accomplish them. The agreement also

details the nurse's hourly professional and administrative

reimbursement.

b. Training Field Nurses. Most commonly training of Field Nurses is done

at the district office location. The training for nurses contracted for this

project should not exceed one and a half days since there is no effective way

to reimburse them for their time. One day should be devoted to discussing

various FEC policies and procedures and one half day should be allocated to

addressing the nurse functions (report compliance and completion, billing

forms and coding schemes).

In those areas where travel by the Field Nurse to the district office would

require several hours or necessitate air travel, the Staff Nurse may wish to

consider travel to cities where the Field Nurses are located. The length of

training and the agenda topics should be the same. A suggested training

outline has been enclosed as Exhibit 5.

c. Managing Field Nurses. Once Field Nurse selections have been made

and memoranda of agreements have been signed, the nurse's name, phone

and address need to be recorded into the Nurse Tracking System, where

available, or into a manual log.

(1) Referring Cases to the Field Nurses.

(a) The Staff Nurse will refer cases to the Field Nurses using

geographic rotation. However, sometimes the special needs of

the claimant rather than locale may dictate the choice of nurse

for a specific case. For example, a claimant with a psychiatric

or neurologic disorder would benefit from the intervention of a

nurse having this kind of expertise. In this instance, the case

would be referred to the nurse having these qualifications

rather than to the next nurse on the rotation.

FECA-PT3 Printed: 08/02/2011

(b) Once the selection is made, a letter which serves as an

authorization to perform these services is forwarded to the

nurse. This authorization letter reiterates the nurse's functions,

responsibilities and reimbursement rate as listed in the

memorandum of agreement. The authorization letter also

includes the claimant's name as well as all available medical

data for use by the nurse in his or her intervention. A sample

of this authorization letter may be found in Exhibit 6.

on each Field Nurse. Data pertaining only to the nurse, e.g.

memorandum of agreement, credentials, warnings or

assessments of his or her work, can be kept in this folder. Any

data pertaining to claimants must be referred to their files.

(2) Field Nurses' Reports. The Field Nurse should complete the

Initial Evaluation Form, as shown in Exhibit 1, and return it to the Staff

Nurse within 30 days after initial contact with the claimant and the

physician. The Progress Report should be submitted to the Staff Nurse

on a monthly basis. However, Field Nurses may submit verbal or

written reports at any time to the Staff Nurse if issues needing

immediate attention arise.

The Staff Nurse should have reviewed and clarified the elements of

each of these reports during the Field Nurse training session. It may

prove useful to review these data elements again when the case is

referred. A supply of these forms may be included in the initial

authorization packet or sent to the Field Nurse under separate cover

with instructions for completion.

(3) Warning and Termination Procedures. The memorandum of

agreement with FEC identifies the responsibilities of the Field Nurse.

When any of these responsibilities are not fulfilled by the Field Nurse,

the Staff Nurse needs to take immediate corrective action.

For example, the nurse's reports are consistently late or there has

been no follow up either by phone or in person with the treating

physician. Such delays may hamper possible return to work

opportunities. The staff nurse needs to issue verbal warnings to the

field nurse after the first two violations, issue written warnings to the

field nurse after the second two violations, and terminate the field

nurse's working relationship with OWCP after the fifth violation,

ensuring that there has been 30 days' prior written notice.

3-0201-13 Other Medical Management Functions of the Staff Nurse

13. Other Medical Management Functions of the Staff Nurse. While the primary

function of the Staff Nurse is to coordinate nurse services, there are other medically

related activities which require his or her expertise. These areas include:

a. Complex Medical Bills. The automated enhancements to the medical

bill processing system will suspend bills for a variety of medical issues. The

FECA-PT3 Printed: 08/02/2011

nurse may be called on to evaluate such issues as: assessing the relatedness

of a procedure to the accepted condition; clarifying the need for continued

prior authorized services (physical therapy, TENS units, home nursing

services); resolving excessive charges submitted by consultant physicians;

and performing random quality control reviews of bills after payment

approval.

b. Training on Medically Related Issues. The nurse may offer training to

CEs and other district office staff on an as-needed basis using any of the

following methods:

(1) A one-on-one session would be appropriate at the time a CE

requested information pertaining to a treatment modality, i.e., a

specific drug, diagnostic examination or operative procedure.

(2) An informal group session may prove helpful if the nurse is

approached by a Supervisory CE (SCE) to assist the module in a

specific issue, e.g., formulating the questions posed to treating,

second opinion and referee physicians.

(3) Formal group sessions may be organized when the nurse

identifies the expertise of a medical consultant, either in-house

(DMD/DMA) or from outside the Office, and arranges for that doctor to

discuss his or her specialty with the CEs and other office staff.

Training by the nurse may also be initiated with new DMDs/DMAs,

contact representatives and office staff resolving bill problems.

3-0201-14 Billing by the Field Nurse

14. Billing by the Field Nurse. Billing periods are to correspond to the report

(either Initial or Progress) service periods, i.e., monthly, and the program will not

accept bills that arrive without a report. A bill must not contain charges for services

that fall outside the billing period or for unpaid balances from prior billing periods.

a. The following requirements must also be met for reimbursement

approval:

(1) Form. The only acceptable billing form will be the HCFA-1500.

(2) Codes. Only the specific internal codes with appropriate

terminology and dollar amounts designated for professional and non-

professional services will be acceptable.

(3) Submission of Bills. A HCFA-1500 needs to be completed in

duplicate for each claimant receiving nursing service. A duplicate

report (initial/progress) must also be attached to the duplicate HCFA

form. The words "PROMPT PAY" should be written at the top and

bottom of the original HCFA billing form. The envelope should also be

marked "PROMPT PAY" to the attention of a designated individual. A

sample of a correctly completed HCFA-1500 form is shown as Exhibit 7

(Link to Image).

FECA-PT3 Printed: 08/02/2011

3-0201-15 Functional Capacity Evaluations (FCEs)

15. Functional Capacity Evaluations (FCEs). These evaluations may

be classified in two types according to their purpose, duration and

content: a general-purpose FCE, and an FCE for placement into an

Occupational Rehabilitation Program (ORP) such as Return to Work or

Work Readiness (commonly called work-hardening, work conditioning,

etc.)

a. A CE or SN may authorize a general-purpose FCE in cases

where management of disability calls for clarification of job tolerances,

job modifications, etc., and the treating physician, second opinion or

referee specialist recommends or requires this service. However, only

a Rehabilitation Specialist can authorize an FCE in connection with an

ORP (see PM 2-813).

b. Before authorizing the FCE, the CE or SN should review the

case and verify that the injury occurred more than three months ago,

the functional impairment is of moderate to high complexity, and the

services recommended by the physician exceed routine physical

performance tests and measurements (e.g. CPT 97750). More

detailed guidelines appear in Chapter 1 of MEDGUIDE.

c. The CE or SN advises the recommending physician that the FCE

is approved. Based on the severity of the case and whether or not any

complicating factors are present, up to eight hours can be approved

for a general-purpose FCE.

d. The CE or SN completes the authorization form and enters the

authorization in the "Notes" section of the Case Management File

(CMF). To ensure the accurate processing of bills for the FCE, the

following information must be included: the approved service code, the

number of hours approved, the name of the provider, and, as

necessary, the use of modifiers.

The CE or SN also notifies the Field Nurse (FN) assigned to the case of the

authorization of the FCE and provides the FN with a copy of the authorization.

3-0201 Exhibit 1: Initial Evaluation of Claimant

TO: NAME OF CE OR COORDINATOR File #:

FROM: NAME OF NURSE ICD-9 Accepted

Condition:

PHONE #: NURSE'S TELEPHONE NUMBER

Claimant Name: Address:

FECA-PT3 Printed: 08/02/2011

Primary Physician: Address:

Phone:

Employer:

A. PERSONAL INFORMATION

Family Dynamics and Home Situation (detail only those factors

which relate to claimant's return to work):

B. JOB HISTORY

Description of Injury (including date of injury):

INITIAL EVALUATION OF CLAIMANT, Continued

C. MEDICAL HISTORY

Current Medical Status (include consulting physicians)

History of Previous Injuries

Non-Injury-Related Medical Conditions

Current Medications

FECA-PT3 Printed: 08/02/2011

Physician(s) Contacts/Conclusions

D. NURSING CARE PLAN

Potential Problems

Recommendations

Planned Services During the Next 30 days

Planned On-site Visit to Agency/Work Site

3-0201 Exhibit 2: Progress Record

Report Date:

Claimant Name: Case File #:

Claimant Address: ICD-9 Accepted

Condition:

Name of Nurse: Phone:

A. DATES OF SERVICE

From: To:

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B. SUMMARY OF PROGRESS TO DATE

C. ACTIONS TAKEN DATES

D. NURSING CARE PLAN

Planned Services For the Next 30 Days

Potential Problems Recommendations

3-0201 Exhibit 3: Sample Advertisement for Nurse Services

The U.S. Department of Labor, Federal Employees' Compensation Program (FEC) is

currently seeking to contract with nurses to work with claimants and their treating

physicians to coordinate treatment, promote recovery and ultimately facilitate the

return to work of the claimant.

An applicant must have the following minimum qualifications to be considered for

this service: a registered nurse (R.N.) license; at least two years of general medical-

surgical clinical experience; and at least two years of case management experience.

Additional expertise desired includes: a basic knowledge of workers' compensation

injuries and illness; excellent oral and written communication skills; good

organizational and time-management skills, and proven decision-making abilities.

Selection will be based on the combination of education and expertise that best

meets the needs of the Department of Labor.

The hourly rate for a contract registered nurse is $00.00 for professional services

and $00.00 for administrative services.

If you wish to pursue this opportunity, please submit your curriculum vitae showing

the qualifications as listed above, along with a copy of your current nursing license

FECA-PT3 Printed: 08/02/2011

to:

DISTRICT OFFICE ADDRESS

All applications must be received in this office no later than DATE.

If you need further information, you may contact:

NAME, TITLE AND PHONE NUMBER

OF DISTRICT OFFICE CONTACT

3-0201 Exhibit 4: General Selection Guidelines

GENERAL SELECTION GUIDELINES

Describe qualifications under the following categories:

A. Nursing Degree (R.N.) License Number____________

B. Clinical Experience Dates

Specialty

General Medical-Surgical

Emergency

Critical Care Unit (CCU, ICU, etc.)

Other

C. Positions Held Dates

Staff Nurse

FECA-PT3 Printed: 08/02/2011

Team Leader

Head Nurse

Other

D. Additional Experience Factors

- demonstrates in the C.V. that he/she has medical case

management experience.

- shows workers' compensation case experience through past

positions held, e.g. with DOL, State or private sector

carrier.

3-0201 Exhibit 5: Suggested Training Topics

SUGGESTED TRAINING TOPICS

A. Introduction

- Overview of Nurse Intervention

- Objectives of the Training

B. Training Outline

The Federal Employees' Compensation Program: CA-810

and CA-550

1. Coverage of FECA

- Constituency (variety of occupations)

- Kinds of Claims--traumatic,occupational diseases

- Kinds of Benefits--compensation, medical,

vocational

rehabilitation etc.

- Philosophy of the program--non-adversarial

- Organization of program; geographical distribution,

district office structure

2. How claims are adjudicated and managed (brief description)

FECA-PT3 Printed: 08/02/2011

- Notice of Injury

- Forms CA-1 and CA-2

- Acceptance, ICD-9 diagnoses codes

- Continuation of Pay

- Compensation, short/long term

- Reemployment and Vocational Rehabilitation

3. Nurse Intervention Process

- Roles/responsibilities

- Reporting Mechanisms

- Claimant/Physician Communication

- Billing Procedures

- Security of Files

- Schedule for additional training/problem-solving

sessions

4. Tour of the District Office

3-0201 Exhibit 6: Sample Letter Authorizing Nurse Services

Case File #:

Claimant Name:

Employing Agency:

Dear NAME OF NURSE:

This letter serves as a referral and authorization to you to provide medical

management services to the above-named injured worker. It also serves as

notification that you may contact the treating physician to coordinate the medical

treatment, and the employing agency to clarify the requirements of the injured

worker's job. As previously discussed, your hourly rate will be $00.00 for

professional services and $00.00 for non-professional charges. There is a $3,000 or

60 hours of nursing service maximum limit per case. On an exception basis, one

extension only can be authorized, so that the total services per case may not exceed

120 hours or $6,000.

In case(s) assigned to you, your responsibility will be to communicate directly with

the injured worker and his/her family as deemed necessary to explain and monitor

medical treatment and progress. As needed, you will obtain concrete work

limitations and communicate directly with physician and agency about light duty

opportunities.

Enclosed is a summary of case information and the significant medical reports for

your official and confidential use. This information must be kept in a secure location

which only you have access to. When the case is closed, please return the case

information to this office. The case information supplied to you is the property of

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OWCP and cannot be discussed with parties other than the claimant, (claims

examiner/ coordinator), physician and employing agency.

Should you have any questions or comments regarding the contents of this letter,

please contact NAME OF CE OR COORDINATOR on PHONE NUMBER.

Sincerely,

STAFF NURSE

3-0201 Exhibit 7: Prompt Pay Authorization (Link to Image)

CHAPTER 3-0202 - CONTRACT FIELD NURSE

CERTIFICATION

TABLE OF CONTENTS

Paragraph and Subject Date Trans. No.

Table of Contents 03/95 95-12

1. Purpose and Scope 03/95 95-12

2. Certification Process 03/95 95-12

3. Field Nurse Allocation 03/95 95-12

4. Recruitment 03/95 95-12

5. Nurse Selection Method 03/95 95-12

6. Interview 03/95 95-12

7. Notification To Applicants 03/95 95-12

8. Certification Training Workshop 03/95 95-12

9. Option Year Renewal 03/95 95-12

10. Contract Field Nurse Management 03/95 95-12

11. Referring Cases To The Field Nurse 03/95 95-12

12. Tracking Contract Field Nurse Intervention 03/95 95-12

13. Warning and Termination Procedures 03/95 95-12

Exhibits

1. Optional Form (OF) 612 Application

Form (Link to Image) 03/95 95-12

2. Completion Instructions for Optional Form 612 03/95 95-12

3. Scoring Instructions for Contract Field Nurse

Applications 03/95 95-12

4. Scoring Sheets 03/95 95-12

5. Sample Response to Field Nurse -- Acceptance 03/95 95-12

6. Sample Response to Field Nurse -- Denial 03/95 95-12

7. Organizational Timetable for Certification

Process 03/95 95-12

8. Contract Field Nurse Evaluation Form 03/95 95-12

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3-0202-1 Purpose and Scope

1. Purpose and Scope. The program uses contract field nurses to perform nurse

intervention in Quality Case Management (QCM) cases as well as in other case

management initiatives. This chapter describes and standardizes the Office of

Workers' Compensation Programs' (OWCP's) procedures for soliciting, recruiting and

selecting contract field nurses.

In addition, the chapter also defines the role of the staff nurse in managing and

tracking the activities of the contract field nurse.

Each district office will contract with the specific number of nurses which have been

identified as the number needed to adequately serve the injured workers within a

specific geographical area. The staff nurse will act as the coordinator at the district

office level. The National Office will assist in the certification process by coordinating

the solicitation for contract nurses on a national basis, sending out the application

packet to applicants and responding to certification questions or concerns raised by

the staff nurse or other individuals.

3-0202-2 Certification Process

2. Certification Process. The certification process provides for a standardized

approach for procuring the services of contract field nurses. This process consists of

soliciting, recruiting, selecting and contracting with registered nurses to work with

claimants. The contract or memorandum of agreement is valid for a period of two

(2) years. After this initial period, field nurse services may be renewed yearly for

three option years. National certifications of field nurses occur at five (5) year

intervals, however the individual district offices may hold local certification drives

when needed. The staff nurse determines that additional field nurses are necessary

to fulfill specific needs when:

a. Field nurses voluntarily withdraw from OWCP's program and need

replacement.

b. The number of claimants requiring the services of a field nurse

increase in a certain geographic area.

c. The performance of a field nurse (late reports, refusing case referrals)

may prompt the staff nurse to discontinue referrals to particular nurses and

require additional recruitment.

d. Option year attrition occurs.

Once the need for a local certification drive is established, the district office submits

a memo requesting additional field nurses to the Chief, Branch of Medical Standards

(BMSR) in the National Office for consideration. The letter must contain: the

anticipated dates and location of the training, the geographic areas involved by zip

code clusters, and the number of field nurses needed to satisfy the additional need.

After the request is approved, the Chief, BMSR, determines the schedule for the

additional certification training workshop and ensures the availability of adequate

support resources.

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3-0202-3 Field Nurse Allocation

3. Field Nurse Allocation. The FEC staff nurse (SN) in each district office

determines the number of field nurses (FN) needed for each geographical area and

reports the number to BMSR. The staff nurse may use the same allocation or

clustering established for the vocational rehabilitation counselors. A cluster consists

of a number of adjacent zip codes grouped together based on reasonable size, ease

of travel within the cluster, and the number of claimants located within this area.

Once the geographic unit or cluster is established, automated reports detailing the

number of claimants residing in the cluster can be obtained. The staff nurse uses

this information and her own experience to establish the number of nurses needed in

the cluster. This number is then reported to BMSR.

3-0202-4 Recruitment

4. Recruitment. Solicitation for the services of registered nurses to perform

contract field nurse activities is made both at the National and District Office levels.

a. The Chief, Branch of Medical Standards and Rehabilitation (BMSR),

places the advertisement in the Commerce Business Daily and in other

selected national publications (ANA newsletter, National Black Nurses'

Association newsletter, etc.)

b. The district office conducts advertisement at the regional level in local

nursing organization newsletters, and newspapers. The names of nurses who

have previously expressed interest in joining the program should be

maintained in a file so that they are included in the

district office solicitation. Field nurses who are currently certified also need to

be mailed a copy of the advertisement by the district office.

c. The advertisement contains the minimum qualifications required, the

geographical region(s) for which the field nurses are needed, instructions for

responding and a response due date. If the district office plans to conduct

interviews as part of the selection process, this also needs to be mentioned in

the advertisement.

d. BMSR receives the responses to the advertisement, categorizes these

responses by geographic area and distributes a list to the district offices.

BMSR sends all timely respondents an application package. Only responses

postmarked on or before the due date are processed further; late respondents

will be notified that they are not eligible for this certification but will be

notified when an advertisement is placed for the next certification. The DO

staff nurse maintains alphabetically organized late response files for this

purpose.

3-0202-5 Nurse Selection Method

5. Nurse Selection Method.

a. The Staff Nurse in each DO acts as the coordinator for the selection

process. Upon receipt of the completed application forms (OF-612 is shown

in Exhibit 1 (Link to Image)), the staff nurse, or designated district office

staff, compiles them by geographic area/cluster, ensuring that only

applications received on a timely basis are included. Late applications will not

be rated and the applicants will be sent a postcard by the district office

explaining the rejection.

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b. The Field Nurse Panel evaluates the applications from the field nurses

based on pre-determined criteria and selects qualified candidates to be part of

the OWCP nurse intervention program. The panel is composed of the district

office staff nurse and national office staff. The panel members evaluate each

application independently, and then, via telephone, reach a consensus

regarding the ranking of the field nurse candidates. As needed, a third panel

member may be used in those circumstances when a "tie-breaker" decision is

needed.

c. The panel uses the scoring sheets (see Exhibits 3 and 4) to rate each

application considering the following factors: work experience in case

management, specialized nursing skills, educational background and

certifications. The first step in the rating is to verify that the applicant meets

the minimum requirements by checking Block 13. If no R.N. license number

is listed, or if there is no photocopy of the license attached, the reviewer does

not proceed and the applicant is disqualified.

In addition, the other minimum requirements of two (2) years generalized

medical/surgical clinical experience and two (2) years in case management or

an equivalent (Block 8) need to be clearly indicated in the applicant's work

experience. Absent these factors, the applicant is disqualified. An

unsatisfactory performance evaluation should be grounds for non-selection.

d. The specific aspects of how to score experience and education are

detailed further on the instruction sheet attached to the rating form (see

Exhibit 2). Each member needs to obtain a copy of the candidates OF-612

application form and the rating sheet. Data contained on this sheet is self-

explanatory. However, it is important to document reasons for disqualifying

an applicant. It is also important to indicate the reason(s) for 0 points in any

category. When the rating process of an application is completed, panel

members total the number of points awarded in each section, sign and date

the rating form.

e. Ranking and Selection.

(1) Panel members rank the qualified applicants by the total

number of points awarded on the application form, placing the

applicant with the most points at the top of the list. In cases where

applicants receive identical scores and one is above the cut-off line but

the other is not, each is selected for certification.

(2) Once the list is completed, panel members draw a cut-off line

so that the number of applicants above the line corresponds to the

number of field nurses that the district office wants to certify.

(3) All application materials are returned to the staff nurse

coordinator.

(4) The staff nurse takes the applications of those considered

qualified and verifies the accuracy of the licenses with the applicable

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state licensing board for currency and good standing status. In

addition, the name and/or company which employs the field nurse

needs to be checked against the U.S. General Services Administration

(GSA) list of Excluded Parties From Federal Procurement Programs.

This monthly publication identifies those parties excluded throughout

the U.S. Government from receiving Federal contracts. If the nurse or

company employing the nurse appears in the book, the applicant

cannot be selected. A field nurse who is not selected for this reason

needs to be notified that his or her non-selection was based on this

information. The publication can be procured from the regional

OASAM office or electronically from G.S.A.

3-0202-6 Interview

6. Interview.

a. At this point in the selection process, the staff nurse may interview

those eligible candidates in the office's regional jurisdiction who are within a

competitive range. For the purpose of nurse certification, a competitive range

is defined as the number of nurses who are qualified and selected plus those

who are qualified but not selected. Within this group the staff nurse defines a

fair and reasonable number of nurses to interview. To do this, the staff nurse

considers her own time constraints and the availability of the candidates.

Since an interview is a subjective process, and the points earned from this

process should not substantially alter the original rating score. For this

reason, the points assigned to an interview should not exceed three (3).

b. The selecting official (staff nurse) has the authority to determine the

extent of the competitive range based on a fair and reasonable estimate. For

example, if the pre- determined number of nurses for a specific area is 10,

and 15 applicants are found qualified, the interview should include all 15.

However, if the pre-determined number for an area is 10 and 35 applicants

are eligible, it is not reasonable to interview the 25 additional applicants.

c. Questions posed during the interview must:

(1) Be the same for everyone.

(2) Relate to job performance, the strengths/ weaknesses te

applicant brings to the job, and what is expected of him or her.

(3) Be documented together with the applicant's response.

3-0202-7 Notification to Applicants

7. Notification to Applicants. At the conclusion of the rating or interview

process, whichever is the final selection factor, all nurses are notified of their

individual status. Nurses selected for the program are made aware of the selection

and given the necessary information on the certification training workshop. Those

not selected will be given reasons for this action. Sample acceptance and denial

response letters are included in Exhibits 5 and 6.

3-0202-8 Certification Training Workshop

8. Certification Training Workshop. The certification process ends with the

training workshop. Throughout the course of the certification process, the staff

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nurse prepares for the training session. A suggested organizational time table has

been developed for the staff nurses' use in planning the workshop and can be

referenced on Exhibit 7.

The training will typically last only one day since there is no effective way to

reimburse the nurses for their time. The training is divided into two parts: a

description of the FEC policies and procedures, and the contract nurse responsibilities

(e.g. report compliance and completion, billing forms and coding schemes, etc.) At

the completion of the Certification Workshop the staff nurse ensures that all newly

certified field nurses sign and date a new memorandum of agreement. It is at this

expiration date that the option years begin.

It may be necessary to conduct the workshop more than once if the number of

nurses is very large or if the geography is such that prolonged travel is required to

reach the city where the training is held.

3-0202-9 Option Year Renewal

9. Option Year Renewal. On each option year the staff nurse will need to decide

whether to renew the services of each field nurse. To do that, the staff nurse

reviews the field nurse's work performance in terms of timeliness, quality, billing

characteristics, intervention successes, compliments or complaints received from

employing agencies, claimants, FEC staff, presence or absence of verbal and/or

written warnings. This yearly evaluation is a composite of all the case-related

evaluations performed when a case is either closed or transferred to another field

nurse. A sample of this evaluation is found on Exhibit 8. Each field nurse is notified

by letter as to whether his or her contract was renewed or not for the option year.

If the contract is renewed, the field nurse signs another memorandum of agreement

providing the staff nurse with updated information (R.N.license expiration date,

home address/phone changes). The staff nurse also assesses whether another

training (abridged) session is necessary. Applicants will be notified if a training

session is planned. BMSR also needs to be made aware of the training schedule.

3-0202-10 Contract Field Nurse Management

10. Contract Field Nurse Management. Staff nurses will be responsible for the

managing of contract field nurses within their geographical jurisdiction. The staff

nurse will: maintain all manual and automated records referring field nurses,

generate case referrals, supervise their work performance and provide them with

periodic reviews, reserving the authority to terminate those field nurses whose

performance is not in keeping with OWCP policies and procedures. A more extensive

explanation of the staff nurses responsibilities in managing the field nurse activities

may be found in the FECA PM Chapter 3-0201.

3-0202-11 Referring Cases to the Field Nurses

11. Referring Cases to the Field Nurses.

a. The staff nurse will refer cases sequentially to the field nurses using a

geographic rotation. The district offices may use an automated system, i.e.,

Rehabilitation Tracking System (RTS), Nurse Tracking System (NTS) or

maintain the rotation through use of a manual log.

The rotation is based on a geographic match between the first three digits of

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injured worker's zip code and that of the field nurse. Ideally, the field nurse

should be located within 25 miles of the injured worker's residence but may

be located as far away as 50 miles. If there are no available field nurses

within a 50 mile limit, the staff nurse may refer the case to the field nurse

having the best method of access to the injured worker even if that nurse is

located in a different zip code area. This situation typically occurs when the

injured worker is on the border of one geographic cluster, it may be more

efficient in time and money to assign a field nurse from a different zip code

range or cluster since it is closer geographically.

b. Sometimes the special needs of the claimant rather than locale may

dictate the choice of a nurse on a specific case. When a particular case

requires special skills or knowledge that the next field nurse in sequence does

not possess, the staff nurse may select the field nurse out of sequence.

Documentation as to the reason for not following the rotation needs to be

maintained in whatever system is in use (manual or automated system) in

the district office.

c. Once the case assignment is made, a letter which serves as an

authorization to perform these services is forwarded to the field nurse. This

authorization letter reiterates the nurse's functions and responsibilities as

listed in the memorandum of agreement. In addition to the authorization

letter, the field nurse will also receive relevant CA forms, all available medical

data (reports and objective findings) and the Form OWCP-5.

d. The staff nurse maintains a file on each field nurse. Data pertaining to

the nurse such as a copy of memorandum of agreement, credentials,

warnings and/or assessments of his or her work can be kept in this folder.

3-0202-12 Tracking the Field Nurse Intervention

12. Tracking the Field Nurse Intervention. Using the data described below, the

staff nurse will be able to analyze various aspects of the program and obtain the

basic statistics necessary to manage the nurse intervention effort. These statistics

include: the number of claimants and nurses participating in the intervention

program at any given time, the duration and result of the intervention by case or in a

cumulative fashion, the rotation of cases among the field nurses and other data.

a. Claimant Data. From the moment a claimant is selected for nurse

intervention, data is entered by the CE on the QCM screen. The staff nurse

will also enter information on the name of the field nurse and the date the

case was referred out. A return to work date is also captured on this screen.

b. Field Nurse Data. Information regarding the field nurses should also

be maintained including the name of each nurse, home address, phone

number and geographical location.

3-0202-13 Warning and Termination Procedures

13. Warning and Termination Procedures. The memorandum of agreement with

OWCP identifies the duties and responsibilities of the field nurse. When any of these

responsibilities are not fulfilled by the field nurse, the staff nurse needs to take

immediate corrective action in the form of a warning. At any point in the

warning/termination process, the staff nurse may opt to decrease the workload of

FECA-PT3 Printed: 08/02/2011

the field nurse as an incentive for a change in behavior. The decrease in workload

needs to be documented and maintained only for a finite time period. If the field

nurse's work improves, she is restored to the rotation. If there is no improvement,

the staff nurse proceeds with the verbal warnings. If there is a serious violation of

ethics such as breach of confidentiality, falsifying documents or other fraudulent

activities, dismissal is immediate.

The staff nurse needs to document each stage of the termination process by entering

the date and type of violation and the date and type of staff nurse response (verbal

warning, final letter etc.)

a. Verbal Warning. The staff nurse may issue a verbal warning when the

field nurse demonstrates a lack of professionalism or violates any of the

conditions in the memorandum of agreement.

b. First Termination Warning Letter. The staff nurse will send the "First

termination warning letter" after he/she has issued a verbal warning within a

twelve-month period and the field nurse continues to demonstrate a lack of

professionalism or violates the conditions of the memorandum a second time.

Copies of this letter are placed in the field nurse's file.

c. Final Termination Letter. The staff nurse will send a termination letter

when the field nurse continues to demonstrate a lack of professionalism or

violates conditions of the memorandum again within twelve months after

receiving the first termination warning letter. The staff nurse calls the field

nurse and advises that, as of the date of mailing, no further services should

be provided or billed for because his or her cases have been transferred to

another field nurse. A copy of this letter is also placed in the field nurse's file

and sent to the Regional Director and Chief, BMSR.

d. Reconsiderations and Appeals. The field nurse may request a

reconsideration or appeal within 30 days after receiving a termination letter

or, in the case of appeals, a reconsideration decision. A reconsideration

request should be accompanied by relevant evidence to support the field

nurse's arguments. The Regional Director will decide all reconsiderations

within 90 days of receiving the request. The Director, Planning, Policy and

Standards Division in the OWCP's National Office will decide all appeals based

on the evidence of record within 90 days of receiving the request.

3-0202 Exhibit 1: Optional Form (OF) 612 Application Form (Link to Image)

3-0202 Exhibit 2: Completion Instructions For Optional Form 612

INSTRUCTIONS TO APPLICANTS:

This application form is being forwarded to you in response to the OWCP solicitation

to contract with registered nurses for early intervention of injured employees.

Please complete only those items listed below and return to (Name/Address of the

District Office) postmarked no later than (Insert Date).

FECA-PT3 Printed: 08/02/2011

The information which you submit on this OF-612 Application Form will be compared

to the minimum requirements developed by OWCP for contract field nurses. The

minimum requirements are:

1. Evidence of two years' specialized case management experience (experience

can be in workers' compensation, occupational or community health, utilization

review, discharge planning or rehabilitation nursing (Block 8).

2. Evidence of two years' general med-surgical clinical experience (Block 8).

3. Evidence of a valid, current R.N. license. Your R.N. license number(s) needs

to be present in Block 13 or a photocopy of the license needs to be attached to the

application.

4. All applications must be accompanied by your latest performance appraisal.

If this appraisal is more than five years old, please submit three letters of reference

from three clients (employers).

Failure to meet the above requirements or to return the form by the deadline date

will result in disqualification of your application.

ITEM NO. EXPLANATION

4, 5, 7 Personal data--self-explanatory.

6 Applicant's home address (NOT employer's).

8 (Include prior work with OWCP)

In describing your most recent work experience, CLEARLY indicate

evidence of:

(1) case management skills (identify experiences in workers'

compensation, occupational or community health, utilization review,

discharge planning, rehabilitation nursing.

(2) at least two years in general med-surgical nursing.

(3) any specialized clinical nursing expertise e.g. ICU, CCU,

neurology, orthopedics, psychiatry.

Additional sheets may be used if necessary

10-12 Educational Data. Self-Explanatory. This section must at a minimum

indicate that applicant attained: Associate Degree, Diploma or

Bachelor's Degree.

Graduate level degrees will be awarded points on the highest level of

college work completed.

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13 Other Qualifications.

An additional sheet may be used for this section if necessary.

** At a minimum this block MUST contain an R.N. license number(s)

or a photocopy of the R.N. license must be attached. If this info is

missing, applicant is disqualified.

Additional items to address in this area include:

(a) when applicable, certification credentials, e.g. COHN, CCM, CIRS

etc.

(b) special skills when applicable e.g. psychiatric, catastrophic nursing

expertise.

18 Signature.

This certifies that all information completed in the specific blocks is

correct.

3-0202 Exhibit 3: Scoring Instructions for Contract Field Nurse Applications

SCORING INSTRUCTIONS FOR CONTRACT FIELD NURSE APPLICATIONS

Introduction

These sheets will be used by the reviewer to score the applicant's information

submitted on the Optional Form (OF) 612 and supplemental sheets.

Information on the OF-612 will be compared to the minimum requirements

developed by OWCP for contract field nurses. The minimum requirements are:

1. Evidence of two years' specialized case

management experience (experience can be in workers'

compensation, occupational or community health,

utilization review, discharge planning or

rehabilitation nursing). (Block 8)

2. Evidence of two years' general med-surgical

clinical experience. (Block 8)

3. Evidence of a valid, current R.N. license.

R.N. license number needs to be either present in

Block 13 or a photocopy of the license needs to be

attached to the application.

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4. The latest performance appraisal. If this

appraisal is more than five years old, three letters

of reference from three clients (former employers)

MUST also be enclosed.

In scoring the application, it is important for the reviewer to first check to see if the

work experiences indicating case-management and med-surgical expertise as well as

the R.N. License Number/photocopy of license are present. If any of these factors

are NOT present, the candidate is disqualified and no further review of the

application is necessary.

3-0202 Exhibit 4: Scoring Sheets

SCORING SHEETS

The following three items reflect the minimum requirements and must be clearly

indicated on applicant's form. If any of the three items are not present, discontinue

your review, applicant is disqualified.

Block # Data Score

8 Review for Specialized Experience

Applicants must show two years' case

management work, e.g., Workers'

Compensation, Occupational/Community

Health, Utilization Review, Disc.

Plan., Rehabilitation Nursing.

** If none appear, Disqualify N= 0

If 2-3 years' experience 2

If 3 + years' experience 3

Review for Med-Surg Experience

Applicant must clearly show minimum

of two years' general med-surg. work

** If none appear, Disqualify N= 0

If 2-3 years' experience 2

If 3 + years' experience 3

13 Check for R.N. license numbers

** If no license number is indicated or

photocopy of the license is not attached,

Disqualify N= 0

R.N.#=1

The additional items are to be scored in addition to the above

requirements.

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4-7 Personal Data N= 0

8 Work Experience

Review for previous work with OWCP

- accepts cases most of the time (85%) Y= 1

N= 0

- reports/communication timely & complete Y= 1

N= 0

- billing accurate & timely (85%) Y= 1

N= 0

- works well with claimants, staff,

physicians, employing agencies Y= 1

N= 1

- no previous OWCP work experience N= 0

Review for additional areas of clinical

expertise in any of these areas,

e.g., orthopedics, neurology,neurosurgery,

psychiatry, ICU, CCU.

If 1-2 years' experience 1

If 3 + years' experience 2

10-12 Educational Background--

Review for evidence that applicant

earned at least one:

Associate Degree

Diploma

Bachelors Degree 2

Additional points will be given for

the highest level of college work

completed, e.g.:

Masters Degree 1

Ph.D Degree 2

13 In addition to R.N. license number(s),

Other Certifications related to case

management may be entered here, e.g.,

Certification in Occupational Health--COHN,

Certification in Case Management--CCM,

Certified Insurance Rehab. Spec.--CIRS.

No additional points will be given for

this now but at next certification

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additional points will be given.

Total Points=

Name of Reviewer __________________________

Date of Review ____________________________

3-0202 Exhibit 5: Sample Response To Field Nurse--Acceptance

Dear FIELD NURSE:

I am pleased to accept you as an OWCP contract field nurse. To complete the

certification process, a training workshop is planned for:

DATE:

TIME:

PLACE:

Please detach and return the lower portion of this letter to me at the above address.

Your workshop reservation must be postmarked by the following date:

You may contact me at - - if there are any questions on this workshop.

Sincerely,

STAFF NURSE

I will attend the workshop. I will not attend the workshop.

Please print your name:

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Home Address:

3-0202 Exhibit 6: Sample Response To Field Nurse--Denial

Dear FIELD NURSE:

Thank you for your interest in the Office of Workers' Compensation Programs'

(OWCP's) nurse intervention program. As a result of the certification process, I am

unable to select you to provide services to OWCP injured workers for the reason (s)

indicated below:

You are qualified for selection. However, we selected

the maximum number of field nurses needed to provide

services within the geographical area of the District

Office. You may be selected at a later date if we have a

need for new field nurses.

Your application did not meet our minimum

qualifications based on either case management and/or

med-surgical clinical experience.

Your application was incomplete.

Your response to our solicitation for contract field nurses to provide services to our

injured workers is appreciated.

Sincerely,

STAFF NURSE

3-0202 Exhibit 7: Organizational Timetable For Certification Process

WEEKS TO WS ACTION STATUS

10 weeks

1. Determines the number of

or earlierfield nurses, presents

geographic distribution plan

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to RD, NO.

2. Advertises Contract

Field Nurse Position in local

nursing journals, newsletters,

newspapers etc.

3. Coordinates date and

location of the workshop with

DO and NO.

9 weeks

1. Confirms attendance of

district and NO staff (BMSR)

who will deliver welcoming and

closing remarks, as well as part

of the actual training.

2. Reserves space for the

workshop, preferably in a

Federal Building.

3. Ascertains that all

necessary furniture,

equipment, and supplies will

be available.

7 weeks

1. Rejects incomplete

applications.

2. Refers completed forms to

panel for evaluation and ranking.

3. Organizes application

materials after panel

completes selection.

4. Creates folder for "Selected"

Applicants.

5. Creates additional folders

marked "Qualified-Not Selected"

and "Disqualified" Applicants.

5 weeks

1. Completes/mails acceptance

letter or earlier which includes

date/time/place of training

workshop. Include to whom form

should be returned and by what

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date (should be no later than

three weeks before the workshop).

2. Sends notification to the

"Qualified-Not Selected" and

"Disqualified" applicants.

Advise they may discuss non-

selection with staff nurse or

file written appeal for BMSR

review.

2 weeks

1. Compiles training materials,

draws up final agenda, sends

this information to BMSR

for concurrence.

2. Makes sure all available

spaces for the workshop are

filled.

3. Prepares Workshop Attendance

Log.

4. Contacts FNs who did not

respond to the letter and verify

their attendance.

5. Notes the reason for non-

attendance on the log and replace

with field nurses from the

"Qualified-Not Selected" folder.

Confirm new FN attendance by phone

and add name on the Attendance Log

and whom he or she is replacing.

Day Before 1. Checks the physical location

Workshop and set-up of the training

facility.

2. Reminds speakers of the time/

place of the workshop.

Workshop 1. Supervises the sign-in

Day procedure for attendees.

2. Distributes materials and

acts as resource person.

3. Conducts sessions.

FECA-PT3 Printed: 08/02/2011

4. Ensures all participants

complete and sign a Memorandum

of Agreement.

5. Checks that each participant

has provided you with his or her

phone number and home address.

After 1. Ensures that all pertinent FN

Workshop information is entered on either

the RTS or district office

tracking system.

3-0202 Exhibit 8: Contract Field Nurse Evaluation Form

CONTRACT FIELD NURSE EVALUATION FORM

F.N.'s Name:

I.W.'s Name:

Claim File:

Instructions: This evaluation form should be completed when the FN submits the

closure report or when the case is assigned to another field nurse or transferred to

another district office.

Did the FN: Yes No N/A

1. Respond timely to the request

for case referral?

2. Communicate timely and

effectively with IW, AP, EA,

SN, CE and other parties?

3. Identify problems which could

affect the RTW promptly and

accurately?

4. Offer good problem-solving

techniques and/or offer viable

recommendations to OWCP?

5. Only make commitments based

FECA-PT3 Printed: 08/02/2011

on the written approval and

authorization of OWCP?

6. Provide and coordinate necessary

services (e.g., schedule of second

opinion exams) without delay ?

7. Follow the directions of the SN

and CE ?

8. Submit reports and bills timely

and accurately?

CHAPTER 3-0300 - AUTHORIZING EXAMINATION

AND TREATMENT

TABLE OF CONTENTS

Paragraph Subject Date Trans.No.

Table of Contents 06/00 00-07

1. Purpose 10/90 91-02

2. Requests for Authorization 09/96 96-15

3. Form CA-16, Authorization for Examination &/or

Treatment 10/90 91-02

4. Prohibited Authorizations 10/90 91-02

09/95 95-39

5. Medical Facilities Where Care May Be Authorized 10/90 91-02

6. Transfer or Termination of Authorization

for Medical Care 04/95 95-17

06/00 00-07

7. Peace Corps Cases 10/90 91-02

(Pagination only) 04/95 95-17

Exhibits

1. Authorization for Examination and/or Treatment 12/94 95-04

(Link to Image)

3-0300-1 Purpose

1. Purpose. The purpose of this chapter is to describe the circumstances under

which OWCP or, in some instances, the employing agency may authorize medical

services for injured claimants. The methods of authorization and when they should

be used are also described.

3-0300-2 Requests for Authorization

2. Requests for Authorization. While claims personnel receive the majority of

requests for examination and treatment, the Medical Unit may receive some requests

as well.

FECA-PT3 Printed: 08/02/2011

a. Types of Treatment Requested.

(1) Emergency. If an emergency exists, the DMA may authorize

treatment by telephone. Otherwise, the caller should be advised that

the physician should submit a written request detailing the type of

treatment recommended and the reason it is needed.

Authorization is sometimes requested for a non-emergency procedure

scheduled for the immediate future. If the authorization cannot

properly be given by the date in question, the caller should be asked

to submit a written request as described above and advised that if the

request is approved, payment may be authorized after the fact.

(2) Surgery. Authorization for surgery should be obtained in

advance whenever possible in order to ensure payment. Even if

surgery is undertaken without OWCP approval, however, the cost may

be reimbursed if the procedure is later found to be acceptable. See

FECA PM 3-400.5b(1) for a description of the criteria used to

determine if surgery should be approved.

(3) Other Procedures. Requests will normally be handled by the

District Medical Adviser (DMA). In his or her absence, the Medical

Management Assistant (MMA) will obtain all pertinent information and,

with the concurrence of designated claims or managerial personnel,

determine whether authorization should be given.

b. Contractual Obligation. Authorization by OWCP for medical

examination and/or treatment constitutes a contractual agreement to pay for

the services regardless of whether a compensable injury or condition exists.

Moreover, any medical condition resulting from authorized examination or

treatment (such as residuals from surgery) may form the basis of a

compensation claim for impairment or disability, regardless of the

compensability of the original injury. For both of these reasons great care

must be exercised in authorizing medical examination and/or treatment.

c. Documentation. Form CA-110, Report of Telephone or Office Call, or a

memorandum to the file must be completed to document all telephone calls

concerning authorization or denial of examination and/or treatment. Verbal

authorization as well as the issuance of Form CA-16 or a telegram (usually

used only when the claimant is overseas) should always be confirmed in

writing. If the MMA gives the authorization, the DMA will confirm it in writing.

Ordinarily, copies of letters of authorization and forms addressed to

physicians and medical facilities are not sent to the official superior. They

may be provided on request to the claimant or representative as long as the

correspondence contains no sensitive medical information. A letter of

authorization will always be used to arrange for examination of an employee

and/or review of the case file by a specialist.

3-0300-3 Form CA-16, Authorization for Examination and/or Treatment

FECA-PT3 Printed: 08/02/2011

3. Form CA-16, Authorization for Examination and/or Treatment. Form CA-16 is

the vehicle by which the employing agency authorizes examination and/or treatment

at OWCP expense. It is used primarily to refer an employee who sustains traumatic

injury to a local physician or hospital of the employee's choice. OWCP delegates this

authority to the employing agency to allow medical treatment from the time of the

injury until a claim is adjudicated.

a. Traumatic Injury.

(1) Period of Authorization. Form CA-16 (Exhibit 1 (Link to

Image)) limits to 60 days the Office's contractual obligation to pay for

medical services and instructs physicians to contact the district office

for extension of that period. (Previous versions of the form provided

for a 90-day period of treatment, and occasionally an agency will use

such a form to authorize treatment. When this occurs, the bills must

be paid until authorization is revoked.)

(2) Effect of Adjudication. Once a case is accepted, the period of

authorization is automatically extended to cover necessary services for

the accepted condition, and additional authorization is not necessary

unless requested by a provider in a specific case. If a case is denied,

however, authorization for treatment must be revoked even though 60

days have not elapsed. If the case is denied after the end of the 60

day period, the physician will be informed that the injury is not

compensable and that bills will be paid only for services rendered prior

to the end of that period.

(3) Emergency Circumstances. Form CA-16 may be used to

authorize treatment in cases of a doubtful nature, and in emergencies

or unusual circumstances, the Office may approve payment for

medical expenses incurred even if Form CA-16 has not been issued

and the claim is subsequently denied. Payment in situations meeting

these criteria must be determined on a case-by-case basis (see Val D.

Wynn, Docket No. 88-1813, issued March 10, 1989).

If Form CA-16 is inadvertently released to an excluded provider, the

bills should be paid, but a letter rescinding the authorization should be

released immediately to the claimant and provider.

b. Occupational Disease, Latent and Recurrent Disability. The employing

agency must contact OWCP for instructions on providing treatment in cases

where an occupational disease is claimed, when disability recurs more than 90

days after the claimant returns to duty, or when disability begins more than

90 days after an injury for which no report was made to OWCP. From the

employing agency and/or the employee, the Claims Examiner (CE) will

determine the nature and cause of the injury and any treatment which has

been provided for the disability. In exceptional circumstances, OWCP may

permit the employing agency to issue Form CA-16 for examination and/or

treatment, depending on the nature of the injury or alleged injury.

3-0300-4 Prohibited Authorizations

4. Prohibited Authorizations. No authorization for medical care may be given

FECA-PT3 Printed: 08/02/2011

unless a notice of injury or occupational disease has been or is about to be filed (that

is, a notice of injury has been completed and is in possession of the employing

agency). The following kinds of authorization are prohibited:

a. Issuance to Excluded Providers. Although an employee has the right

to choose the initial treating physician, no authorization may be given for

examination and/or treatment by an excluded physician. For further

information regarding excluded providers see Chapter 3-800.

b. Issuance to Oneself. An injured employee does not have the authority

to issue an authorization for examination and/or treatment on his or her own

behalf. For example, if a postmaster sustains an injury, it is expected that

authorization will be secured from the regional office. In an emergency, the

services of the nearest physician or hospital may be utilized without prior

authorization, with the understanding that the employee will contact the

employing agency at the earliest possible time for authorization or

instructions.

c. Issuance to Minors. OWCP does not consider any person under the

age of 18 to be emancipated. Therefore, permission from the parent or

guardian will be needed to authorize treatment of any claimant under 18. If

the parent or guardian is not immediately available for signed consent it may

be necessary to arrange for a witnessed telephone call or to send a telegram

(if the claimant is overseas) to obtain consent. Any expense incurred in order

to do so is payable by OWCP.

d. Issuance to Certain Employees Prior to Separation. Certain groups of

claimants are entitled to FECA coverage by virtue of special legislation. They

include Peace Corps and VISTA volunteers as well as Job Corps enrollees.

While members of these groups are entitled to medical care for accepted

injuries at OWCP expense, authorization for treatment may not be granted

until the volunteer or enrollee is separated from the program.

e. Advance or Blanket Authorization. An authorization for treatment at

some future time, or as the need arises, shall not be issued. When such

authorization is requested the employee should be advised to contact OWCP

in writing as the need for treatment arises, or by telephone or telegram

(where the claimant lives overseas) should the need become urgent.

f. Fitness-For-Duty Examinations. The law does not provide for

examination to determine the "fitness-for-duty" status of an employee. This

is a function of the employing agency.

g. Exposure to Disease. The law does not provide for routine

examination of an employee who has been exposed to a co-worker with an

infectious disease or to hazards of the workplace. Unless there is reasonable

proof that a disease or illness has been sustained by the employee, such

examinations are the responsibility of the employing agency (however, see

PM Chapter 3-400.7a). The decision to authorize examination at OWCP

expense in these cases must be made by OWCP.

3-0300-5 Medical Facilities Where Care May Be Authorized

FECA-PT3 Printed: 08/02/2011

5. Medical Facilities Where Care May Be Authorized. The FECA at 5 U.S.C. 8103

permits the employee an initial choice of physician. Examination and treatment may

be given in the following settings:

a. Emergency Medical Facility. Emergency medical care by private

physicians, clinics or hospitals may be authorized if such care is warranted.

The employee may seek continuing medical care from the physician who

provided the initial treatment or select another local physician.

b. Employing Agency Health Units. These facilities are equipped to

provide immediate assistance and/or to refer employees to local physicians or

emergency care facilities. When indicated, rescue squads or similarly trained

and equipped units may be used to move injured persons.

c. Physician's Office. Ordinarily, the physician selected should be located

within 25 miles of the employee's home or place of employment (in rural

areas, a provider at a greater distance may be authorized).

d. Hospital. The attending physician may arrange for care in a local

hospital. A private room may be authorized only if the condition is such that

the attending physician believes it is medically necessary and the District

Medical Advisor (DMA) concurs. If a private room is used because of the

claimant's personal preference, he or she will be required to pay the

difference in cost. Also, such personal items as television and telephone

service must remain the claimant's responsibility.

e. Federal Medical Facilities. The medical facilities of the Army, Navy, Air

Force, and Veterans Administration may be used to provide treatment if

practicable. Arrangements must be made on a case-by-case basis with the

director of the hospital or clinic (such arrangements should be documented on

Form CA-110, Report of Telephone or Office Call, or in a memorandum for the

file). Use of Federal facilities may not be required to the exclusion of the

claimant's choice of physician.

3-0300-6 Transfer or Termination of Authorization for Medical Care

6. Transfer or Termination of Authorization for Medical Care.

Any transfer of medical care should be accomplished with due regard for professional

ethics and courtesy. No transfer or termination of treatment should be made unless

it is in the best interest of the claimant and the government. The following

guidelines should be observed:

a. Request by Official Superior. The official superior of an injured

employee does not have authority to transfer medical care from one physician

to another. If adequate medical care is not available locally or the employer

feels transfer of medical care is advisable for other reasons, the official

superior should contact OWCP for instructions.

b. Request by Attending Physician. If the attending physician asks to be

relieved of responsibility in a case, the request will be granted. The physician

should be asked to provide his or her reasons for the request, report the

patient's condition at the time, and state any further medical

recommendations.

FECA-PT3 Printed: 08/02/2011

c. Request by Employee. Employees who want to change attending

physicians must explain their reasons in writing, and the CE must review all

such requests.

(1) The CE may approve a change on his or her own authority

when: the original treating physician refers the claimant to another

physician for further treatment; the claimant wants to change from the

care of a general practitioner to that of a specialist in the appropriate

field, or from the care of one specialist to another in the appropriate

field; or the claimant moves more than 25 miles from the original

physician.

(2) The CE must use discretion in cases where other reasons are

presented:

(a) Denial solely on the basis that the claimant did not seek

approval of the change before consulting another physician is

improper (see Cybil L. Slade, 40 ECAB 1029). Rather, the CE

must examine the request to determine whether the treatment

was reasonable and necessary. (See Arron G. Marston, Docket

No. 88-1716, issued March 22, 1989). This assessment may

require referral of the case to the DMA.

(b) A request to change from the care of a specialist to the

care of a non-specialist may not be denied without considering

whether the treatment provided by the new physician is

reasonable and necessary. However, unless the issue has

arisen because care by a specialist is not available, the case

should be referred for opinion from the DMA.

care of a medical doctor to that of a chiropractor, the CE should

consult the DMA to determine whether the services of the

chiropractor constitute medical treatment under the Act and if

so whether it is reasonable and necessary (see Elizabeth J.

Davis-Wright, 39 ECAB 1232).

(3) Cases involving complex medical issues should be referred for

opinion from the DMA.

(4) A second opinion examination may be in order if a claimant

requests transfer to another physician at a time when the treating

physician is recommending return to employment. If a second opinion

is necessary to address issues involving continuing medical care, the

selected physician may not become the treating physician.

d. Questions about Treatment. If the employee is under the care of a

qualified physician and a question arises concerning the physician's medical

management of the case (for instance, the prolonged use of therapeutic

measures or the use of measures of questionable value), it is proper to

FECA-PT3 Printed: 08/02/2011

request the physician's comments, and the DMA may request discussion of

the medical problem involved.

e. Request for Consultation. The OWCP may seek consultation services

with experts in specialized fields, either to provide the attending physician

with guidelines or to determine a future course of action with regard to

medical care. In such cases, the attending physician must be advised of the

action contemplated and told that the findings will be made available to him

or her.

f. Transfer of Care. When it is determined that a transfer of medical care

is needed, the previous attending physician and the claimant must be notified

in writing regarding the change so that the physician may close his or her file

and submit a final bill and report. A suitable explanation should also be

furnished to the attending physician. If appropriate, the physician should be

assured that OWCP's action is not intended as a criticism of his or her

management of the case or professional ability and judgment. The claimant

as well as the physician should be advised that authorization for treatment is

being terminated.

g. Exclusion of Provider. As noted above, OWCP must terminate

authorization for treatment with excluded providers. Both the physician and

the claimant should be advised immediately that further medical treatment is

not authorized and the claimant should be advised to select another treating

physician. The claimant may continue to receive treatment from the excluded

provider at his or her own expense. Exclusion of providers is discussed in

Chapter 3-800.

3-0300-7 Peace Corps Cases

7. Peace Corps Cases. Peace Corps volunteers (including volunteer leaders and

trainees) are covered by the FECA by virtue of special legislation which affects,

among other things, the kinds of medical care which may be authorized. Peace

Corps claims are adjudicated in the National Operations Office, after which they may

be transferred to other district offices if approved. The following procedures apply to

Peace Corps volunteers:

a. Entitlement to Medical Care. A Peace Corps volunteer is entitled to

medical care for any injuries suffered while abroad (which is defined as any

area outside the United States, its territories, the Commonwealth of Puerto

Rico, and the District of Columbia). Except for the exclusions which appear in

Section 8102 of the FECA and Section 5 (d) (2) of the Peace Corps Act,

volunteers have the protection of the FECA for all injuries sustained and

diseases contracted during such service. Trainees assigned to work in the

United States, however, must meet the same burden of proof with respect to

performance of duty and causal relationship as other Federal employees.

b. Initial Authorization for Medical Care. Since these claims are

adjudicated in the National Operations Office, requests for initial authorization

of medical care should be referred there. The following procedure has been

established with regard to issuing authorization for medical care:

(1) Prior to Separation. When a volunteer is in the hospital with a

FECA-PT3 Printed: 08/02/2011

prognosis which indicates that separation from the Peace Corps will be

mandatory, the Medical Unit of the National Operations Office may

verbally approve authorization by the Peace Corps for examination

and/or treatment effective the day following separation, if eligibility for

coverage is established or sufficient indications exist to show that the

condition is related to Peace Corps service, so that continuity of

medical care will be preserved.

(2) At Separation. If eligibility for coverage is established or

sufficient indications exist to show that the condition is related to

Peace Corps service, the National Operations Office may verbally

approve authorization by the Peace Corps for examination and/or

treatment near the volunteer's home.

(3) Following Separation. The Peace Corps may not issue

authorization for examination and/or treatment at OWCP expense to a

volunteer following separation. In such instances, OWCP will issue

authorization and/or instructions to the former volunteer.

(4) Emergency Situations. The Medical Unit in the National

Operations Office may approve the issuance of an authorization

effective the day following termination, prior to receipt of written

documentation, if a medical emergency exists or a delay in authorizing

medical care would seriously affect the continuity of medical

management. The record should show that the agency has completed

Form CA-1 or CA-2 or will ensure that it is initiated and submitted to

OWCP.

c. Coverage for Disease. In cases involving disease, the examining

physician or the DMA must state that the disease was contracted abroad in

order to accept it as Peace Corps related. In some situations, this

determination includes consideration of the incubation period for the disease.

The broad coverage for disease may present unusual medical problems. In

general, the following rules may be observed:

(1) Dental Disease. Caries, abscesses, etc., may be considered

contracted abroad if comparison with the pre-induction dental

examination so indicates. Unless an acute dental emergency exists,

eligibility for coverage will be established prior to issuance of

authorization for dental care. The volunteer may be instructed to

obtain an estimate from a dentist near his or her home at OWCP

expense and submit it to OWCP for consideration. The examination

may include x-rays and prophylaxis, which are payable by the Office.

(2) Mental Illness. If it is determined that the psychiatric condition

is related to Peace Corps service, treatment can be authorized until the

attending physician indicates that the condition or episode has

resolved and that no further disability exists. If a recurrence of the

mental disease is alleged, it must be determined whether the

recurrence is due to the Peace Corps experience or to other factors,

including pre-existing conditions.

FECA-PT3 Printed: 08/02/2011

(3) Parasites. If the separation medical examination indicates the

presence of intestinal or other types of parasites, further examination

and treatment may be authorized. A positive serology or skin test

alone will not necessarily be considered evidence of a disease.

(4) Tuberculosis. If the separation medical examination indicates

the presence of tuberculosis, further examination and treatment may

be authorized, as may provision of INH prophylactic medication.

(5) Pregnancy. It has been determined that the Pregnancy

Discrimination Act requires that FECA coverage be extended to Peace

Corps volunteers for pregnancies which occur during Peace Corps

service overseas and continue past the date of termination. Such

pregnancies are to be considered in the same light as any covered

injury. The coverage is retroactive to April 1, 1979, the date on which

the Pregnancy Discrimination Act became applicable to fringe benefit

programs.

Peace Corps volunteers are covered for all pregnancy- related

conditions, including miscarriages, prenatal and postnatal care of the

mother. Any prenatal care is to be considered part of the treatment

for the disability (pregnancy) of the volunteer, and not preventive

treatment or treatment for the unborn child. Because FECA coverage

is limited to Peace Corps volunteers, the benefits of the Act may not

be extended to the children born of such pregnancies.

Under no circumstances, even when it involves the health of the

mother, may the OWCP pay for an abortion for a Peace Corps

volunteer. This policy is necessary because the Peace Corps is

prohibited from using its funds for abortion, and the Compensation

Fund could not be reimbursed for such expenditure.

(6) AIDS. Peace Corps volunteers are tested for HIV infection

before being sent overseas. If comparison with this test shows that

the infection has developed during the Peace Corps Service, medical

and compensation benefits for the resulting condition are payable.

3-0300 Exhibit 1: Authorization for Examination and/or Treatment (Link to

Image)

CHAPTER 3-0400 - MEDICAL SERVICES AND

SUPPLIES

TABLE OF CONTENTS

Paragraph and Subject Date Trans. No.

Table of Contents 06/00 00-07

1. Purpose 10/90 91-02

2. Statutory Authority 10/90 91-02

FECA-PT3 Printed: 08/02/2011

3. Supplies and Appliances 10/90 91-02

10/95 96-04

09/95 95-39

4. Obtaining Appliances and Arranging for Repairs 10/90 91-02

04/92 92-17

5. Medical Services 04/92 92-17

04/93 93-24

6. Nursing Services 06/00 00-07

04/92 92-17

7. Other Modes of Treatment 04/92 92-17

8. Non-medical Services 04/92 92-17

09/95 95-39

9. Injury or Death While Obtaining Medical Care 04/92 92-17

10. Transportation and Expenses 04/92 92-17

3-0400-1 Purpose

1. Purpose. Many forms of treatment, including diagnostic procedures, may be

authorized by OWCP when prescribed by the attending physician. Similarly, many

supplies may be provided at the request of the attending physician or claimant. This

chapter describes the circumstances under which such treatments and supplies may

be authorized.

3-0400-2 Statutory Authority

2. Statutory Authority. While OWCP generally does not have authority to require

an injured employee to undergo treatment against his or her will, it is assumed that

employees will seek appropriate treatment to restore health and lessen the severity

of impairment. Services and supplies which meet the statutory criteria of being

"likely to cure, give relief, reduce the degree or the period of disability, or aid in

lessening the amount of the monthly compensation" (5 U.S.C. 8103(a)) may be

approved.

3-0400-3 Supplies and Appliances

3. Supplies and Appliances. Specific supplies and appliances and the conditions

under which they may be authorized are as follows:

a. Prescription and Non-Prescription Drugs. In general, drugs and

medications which are necessary to treat an injury or occupational disease

may be purchased at OWCP expense on the recommendation of the attending

physician. These include prescription as well as non-prescription medications.

Cases requiring prolonged use of narcotic preparations, tranquilizers, or

medicinal alcohol must be referred to the DMA for consideration of continued

authorization.

b. Home Medical Supplies and Appliances. Items such as rubbing

alcohol, thermometers, sun lamps, heating pads, analgesics, antacids, etc.,

will not be furnished at OWCP expense unless prescribed by the attending

physician and justified medically. Accepted conditions which may warrant

furnishing such items include such conditions as paraplegia, quadriplegia,

coma, and chronic ulcers. The Claims Examiner (CE) does not need to obtain

approval for the use of these items but may need to consult the District

Medical Adviser (DMA) to determine the frequency with which they are

needed.

FECA-PT3 Printed: 08/02/2011

c. Durable Medical Equipment.

(1) Orthopedic Mattresses or Hospital Beds. These appliances may

be authorized when prescribed by the attending physician to relieve

orthopedic or other medical conditions, but less costly alternatives

such as a bed board should be considered first whenever possible.

(2) Motorized Wheelchairs. The purchase or rental of a motorized

wheelchair may be authorized when the condition necessitating it is

considered to be permanent. Recommendations for this equipment

shall be referred to the DMA for advice regarding authorization.

(3) Other Equipment. Such items as traction apparatus and

walkers for home use may be authorized upon the recommendation of

the attending physician if their use is warranted by the accepted

condition.

d. Prosthetic Devices and Other Personal Appliances.

(1) Glasses and Contact Lenses. Glasses and contact lenses for the

correction of refractive error will be furnished for a condition accepted

as work-related, and subsequent repair or replacement will be

authorized as necessary.

(a) When OWCP accepts a case for loss of vision or loss of

an eye, the purchase of glasses or contact lenses will be

authorized for correction of refractive error in the uninjured

eye.

(b) Prescription sunglasses will be authorized when

recommended by a qualified physician in cases following

cataract surgery. When recommended for another approved

condition, the opinion of the DMA should be obtained prior to

acting on the recommendation.

correct vision in some older patients when cataract surgery is

performed. They may be authorized on recommendation of the

attending ophthalmologist.

(2) Hearing Aids. Hearing aids will be authorized when hearing loss

has resulted from an accepted injury or disease if the attending

physician so recommends. Trial or rental periods should be

encouraged as many persons do not find their use satisfactory.

Maintenance of hearing aids provided by OWCP, including batteries,

repairs, and replacements, may be authorized as needed.

(3) Orthopedic Shoes. If an accepted injury to the foot modifies its

structure so that the employee cannot be fitted with ordinary shoes,

specially constructed ready-to-wear or custom built shoes may be

furnished upon the recommendation of the attending physician. If

FECA-PT3 Printed: 08/02/2011

such shoes will be required permanently, the purchase of two pairs

may be authorized. Alterations to stock shoes usually worn by the

claimant will also be authorized if needed.

(4) Artificial Limbs and Braces. These devices may be authorized

as recommended by the attending physician.

(5) Non-medical Equipment. Items such as waterbeds, saunas,

weight-lifting sets, exercise bicycles, etc., may be authorized only if

recommended by the attending physician and if OWCP finds that the

item is likely to cure, give relief, reduce the degree or the period of

disability, or aid in lessening the amount of monthly compensation.

Procedures for developing and adjudicating requests for such

equipment are provided in PM 2-810.15.

(6) House and Vehicle Modifications. Procedures for developing

requests for modification of houses and vehicles due to the accepted

condition are provided in PM Chapter 2-1800. Requests for items such

as home wheelchair ramps, special automobile attachments, and

window air conditioning equipment should be handled in accordance

with paragraph (5) above.

3-0400-4 Obtaining Appliances and Arranging for Repairs

4. Obtaining Appliances and Arranging for Repairs. Appliances may be either

personal or non-personal in nature.

a. Personal Appliances. Devices which are specifically fitted to and worn

by the claimant, such as back braces, eyeglasses, and artificial eyes are

considered personal rather than government property. Upon the

recommendation of the attending physician, such appliances may be repaired

or replaced without advance approval when the estimated cost is less than

$500. Repairs or replacements costing more than this amount should be

approved in advance by the DMA if possible. The attending physician should

check the repaired or replaced item to ensure a proper fit.

b. Non-personal Appliances. Prior to authorizing any item of a non-

personal nature, the cost of purchase should be compared to the cost of

renting, taking into consideration the prognosis and the estimated duration of

need. Generally, the less expensive method will be used. When the item is

rented, the Medical Management Assistant (MMA) will place a six-month call-

up to assess whether the item is still needed for the accepted condition and if

rental is still less costly than purchase.

A purchased item which can be salvaged when no longer required by the

employee will be considered government property if its retail value is more

than $5000. Such items as hospital beds and wheelchairs fall into this

category, and the employee must be notified in writing at the time of

purchase that the property may be recovered by the government at a later

date. When the item is no longer needed, the MMA will contact at least one

nearby Federal medical facility and offer it for pickup at no expense to OWCP.

If the facility does not wish to acquire the item, the MMA will notify the

regional office of the General Services Administration that the item is

FECA-PT3 Printed: 08/02/2011

available.

c. Repair and Replacement.

(1) The definition of "injury" at 20 C.F.R. 10.5(a)14 includes:

damage to or destruction of medical braces, artificial limbs, and other

prosthetic devices which shall be replaced or repaired; except that

eyeglasses and hearing aids shall not be replaced, repaired, or

otherwise compensated for, unless the damage or destruction is

incident to a personal injury requiring medical services.

(2) Medical braces, artificial limbs, and other prosthetic devices

covered under this provision can be repaired or replaced on a one-time

basis in the absence of any other medical condition resulting from a

work-related incident. OWCP can authorize repair or replacement of

property, such as eyeglasses, hearing aids, and artificial teeth, which

is damaged or destroyed while in the performance of duty only when

the damage or destruction is incident to a personal injury requiring

medical services, or when an accepted condition requires change in a

prosthesis used at the time of injury.

(3) When OWCP cannot authorize repair or replacement, the CE

should advise the claimant that under 31 U.S.C. 240-243, Federal

establishments may settle and pay claims against the United States by

its civilian employees for damage to, or loss of, personal property

incident to employment. The CE should also advise the claimant to

contact his or her supervisor to determine whether a claim may be

made under this statute.

3-0400-5 Medical Services

5. Medical Services. Services which meet the statutory criteria of being "likely

to cure, give relief, reduce the degree or the period of disability, or aid in lessening

the amount of the monthly compensation" may be authorized. The circumstances

under which various kinds of services may be authorized are described below. Any

denial of services requested by the claimant or attending physician must address

these criteria.

a. Emergency Medical Facility. Emergency medical care by private

physicians, clinics or hospitals may be authorized if such care is warranted.

b. Hospital. The attending physician may arrange for care in a local

hospital. A private room may be authorized only if the condition is such that

the attending physician believes it is medically necessary and the District

Medical Advisor (DMA) concurs. If a private room is used because of the

claimant's personal preference, he or she will be required to pay the

difference in cost. Also, such personal items as television and telephone

service must remain the claimant's responsibility.

(1) Surgery. In an elective or non-emergency situation, the file

must be reviewed by a specialist prior to authorizing surgery for a

FECA-PT3 Printed: 08/02/2011

back condition, an organ transplant or a destructive procedure. A

second opinion examination may be obtained at Office expense prior to

authorization for surgery or any invasive procedure (see Chapter 3-

500 concerning second opinion requests). In-house review by the

consultant should occur within 21 days of receipt of the request for

surgery, and any second opinion examination required should be

accomplished within 40 days. Plastic surgery for cosmetic reasons

may not be authorized unless it is performed for a disfigurement of the

face, head or neck which has been accepted by the Office.

(2) Organ Transplants. Organ transplants, except for those which

are experimental or not generally accepted by the medical community,

may be approved upon the attending physician's recommendation and

OWCP's approval consistent with its second opinion procedures.

Ancillary treatment such as immunosuppression is also considered

compensable.

An organ donor is not considered an "employee" within the meaning of

the FECA and is not entitled to compensation for wage loss or

permanent impairment, nor is a donor entitled to benefits for any

complications resulting from the transplant. Only those medical and

related expenses of the donor which are necessary to secure treatment

for the employee are allowable.

(3) Destructive and Questionable Measures. Such procedures as

rhizotomy, injection treatment for varicose veins, chordotomy,

neurectomy, etc., will not normally be authorized solely because of

chronicity of a condition. They may be authorized as a measure of last

resort, after adequate consultation with specialists in the appropriate

field of medicine. Medical or surgical treatment of a questionable

nature will not be authorized without adequate consultations. Second

opinion examinations and OWCP approval are required for any such

procedure.

(4) Substance Abuse Treatment. Where recommended by the

treating physician, the Office may approve a one-time inpatient

substance abuse treatment program up to 28 days in length. Such a

program may be approved even if the Office has not accepted

substance abuse as related to employment in cases where the abuse is

hindering the claimant from participating in a rehabilitation program or

securing employment. The treatment facility should be located within

25 miles of the claimant's home wherever possible, and a cost

comparison between comparable facilities should be made before care

is authorized. Any request for a subsequent course of inpatient

substance abuse treatment should be forwarded to the National Office

for consideration.

Outpatient treatment may be recommended by itself or as a follow-up

measure to inpatient care. Such treatment may be authorized when

recommended by the attending physician, as may medications

prescribed to alleviate the effects of addiction (e.g., Antabuse).

Likewise, counseling in a group setting may be undertaken at OWCP

FECA-PT3 Printed: 08/02/2011

expense.

c. Outpatient or Ambulatory Services. In addition to treatment in the

physician's office, the following may be authorized:

(1) Nursing Services. See paragraph 6 below.

(2) Physical Therapy. For any orthopedic or neurological condition,

physical therapy for a period of 90 days may be authorized if

prescribed by the attending physician. Any therapy in excess of 90

days requires additional medical justification. The time limitation does

not apply to cases involving brain and spinal cord injuries, extensive

second and third degree burns and other conditions which have

rendered the claimant bedridden. (See FECA PM 2-810.16 for a

detailed discussion of authorization of physical therapy.) Work

hardening programs may also be considered on recommendation of

the treating physician.

(3) Occupational and Speech Therapy. These services may be

authorized when recommended by the attending physician for

reasonable periods if improvement or relief of distress is likely to

result. Long term therapy without prospect of improvement shall not

be authorized. Recommendation for such therapy is usually referred

to the DMA for consideration. Occupational or speech therapy may be

authorized when performed in recognized facilities or when rendered

by private providers as long as it is prescribed by the treating

physician and he or she monitors the results.

(4) Lip-Reading Services. On recommendation of the attending

physician, the DMA may approve lip reading services if they would

likely reduce the extent of disability and aid in rehabilitation.

(5) Pain Clinics. The DMA may authorize pain clinic treatment only

if it is appropriate for the accepted condition and the clinic in question

is reputable. Whenever possible clinics connected with universities or

other teaching institutions should be used.

(6) Palliative Treatment. The DMA may authorize such treatment

for prolonged or terminal conditions when the need is adequately

supported by consultants. The therapy may consist of surgical

procedures (rhizotomy), nerve blocks, large doses of pain medications,

and the services of pain clinics or hospices.

(7) Specific Treatments. In addition to the routine diagnostic and

therapeutic services provided in an institution or professional office,

specific forms of treatment may be authorized as follows:

(a) Acupuncture. Acupuncture may be authorized when

recommended by the attending physician to provide relief.

Such treatment shall be supervised by the recommending

physician, who shall submit periodic reports to show progress

or any relief of the symptoms. If the treatment continues

FECA-PT3 Printed: 08/02/2011

beyond six months and/or the results are questionable, the

DMA should be asked for an opinion as to whether the

treatment should continue.

(b) Chymopapaine Treatment. Serious side effects have

been reported from the injection of chymopapaine. Therefore,

any request for this form of treatment must be justified by the

attending physician and reviewed by the DMA.

authorized for a hernia. If surgery is refused or medically

contraindicated, the fitting of a truss may be authorized if

recommended by an examining physician. Injection treatments

are now very rarely used and any such request should be

referred to the DMA for opinion.

(d) Substance Abuse Treatment. Such treatment may be

authorized on the basis of the attending physician's

recommendation. Such a program may be approved even if

the Office has not accepted substance abuse as related to

employment in cases where the abuse is hindering the claimant

from participating in a rehabilitation program or securing

employment.

d. Dental Services. The law provides for repair or replacement of injured

natural and fixed artificial teeth. Except in dental emergencies, prior approval

of OWCP shall be obtained for dental repair or replacement. Before approving

dental repair or replacement, an examination including x-ray and prophylaxis

should usually be authorized and an estimate of the cost of the proposed

dental work must be obtained.

3-0400-6 Nursing Services

6. Nursing Services. OWCP uses the services of in-house Staff Nurses and

contract Field Nurses to coordinate claimants' medical care and aid them in returning

to work. The work of the Staff Nurses is discussed briefly in PM 3-200 and more

thoroughly in PM 3-201. The following guidelines pertain to requests for clinical

nursing services:

a. Licensed or Practical Nurse. The services of these nurses may be

authorized when recommended by the attending physician for therapeutic

services in the home. The services of a nurse may not be authorized to

perform housekeeping duties, however.

(1) Nursing Plans. Nursing agencies routinely develop nursing care

plans for home care which are based on the treating physician's

instructions. A copy of the plans should be obtained to verify that the

nursing care proposed is related to the accepted condition. Absent

such plans, the following questions may be posed to the attending

physician:

(a) What are the chronic sequelae of the work-related injury

and what form of treatment do they require?

FECA-PT3 Printed: 08/02/2011

(b) Are there acute and/or recurrent complications of these

sequelae? How frequently do they appear? What form of

treatment do they require?

treatment of any of the chronic sequelae and/or complications?

How frequently?

(d) What is the anticipated duration of nursing services?

(2) Special Nurses. The services of special nurses may be

authorized when the attending physician certifies that such services

are necessary due to the severity of the claimant's condition. In

questionable cases, the case file should be referred to the DMA for

recommendation. A care plan should be obtained and the approval

period tailored to the needs of the claimant in accordance with the

physician's recommendation.

B Services of Relatives. The attending physician must approve the

qualifications of a relative acting as a nurse to provide the necessary services.

c. Extended Care Facilities. Care in a convalescent home, skilled nursing

facility or hospice may be authorized when the employee does not need acute

care but does require services difficult or impossible to arrange in the home

setting. The recommendation of the attending physician is required in this

situation. OWCP will pay the rates for standard accommodations according to

the requirements of the medical condition. The claimant should remain under

continuing medical supervision of a physician, who may be asked to justify

the continuing need for institutional care every three to six months according

to the severity of the claimant's medical condition.

3-0400-7 Other Modes of Treatment

7. Other Modes of Treatment.

a. Preventive (Prophylactic) Treatment. The FECA does not authorize

provision of preventive measures such as vaccines and inoculations, and in

general, preventive treatment is a responsibility of the employing agency

under the provisions of 5 U.S.C. 7901. However, preventive care can be

authorized by OWCP for the following:

(1) Complications of preventive measures which are provided or

sponsored by the agency, such as adverse reaction to prophylactic

immunization.

(2) An injury involving actual or probable exposure to a known

contaminant, thereby requiring disease-specific measures against

infection. Included among such treatments would be tetanus antitoxin

or booster toxoid injections for puncture wounds; administration of

rabies vaccine where a bite from a rabid animal, or one whose status

was unknown, is involved; or AZT where exposure to HIV virus has

occurred.

FECA-PT3 Printed: 08/02/2011

(3) Periodic examination of the uninjured eye may be authorized

where injury to the other eye has resulted in loss of vision, so that

possible sympathetic involvement of the uninjured eye may be

detected at an early stage. The frequency of these examinations

should be determined on the basis of the attending physician's

recommendations. If sympathetic involvement of the uninjured eye is

found, appropriate medical and surgical treatment for this condition

will be authorized.

(4) Conversion of tuberculin reaction from negative to positive. In

this situation INH therapy may be authorized. Treatment is limited to

the injured employee and cannot be extended to others who may, for

example, have been exposed to an infectious agent by the employee.

b. Adjunct and Ancillary Treatment. Upon the recommendation of the

attending physician, treatment may be authorized for a concurrent ailment if

it appears that such treatment is closely related to the treatment of an injury

and would hasten the cure of the accepted condition(s). Requests for such

treatments may include such regimes as weight loss programs for claimants

with chronic back conditions as well as more traditional therapies such as

treatment of concurrent diabetes in claimants with eye or foot conditions.

The DMA must review all such requests prior to authorization.

c. Experimental Treatment and Clinical Research. All requests for

authorization of the following kinds of treatment or research should be

referred to the OWCP Medical Director following appropriate development:

(1) Experimental diagnostic and treatment modalities or those

which are not generally accepted. Experimental treatment modalities

will be considered if the accepted condition is life-threatening (e.g.,

cancer or AIDS); established therapy has been tried to no avail; and a

significant body of data supports the view that the experimental

procedure is indeed beneficial;

(2) Participation in a research protcol;

(3) Administration of questionnaires, particularly of a sociological or

psychological nature.

Such requests should not be approved or denied without advice from

the National Office.

3-0400-8 Non-medical Services

8. Non-medical Services.

a. Health Club/Spa Membership. Membership in a health club or exercise

facility, or treatment at a spa, may be authorized when recommended by the

attending physician as likely to cure or give relief. Only the facilities required

should be authorized (for example, if swimming is prescribed, the approval

should not include use of exercise equipment as well) and the least expensive

FECA-PT3 Printed: 08/02/2011

facility in the area should be used. Procedures for developing and

adjudicating requests for health club/spa membership are provided in PM

Chapter 2-810.15.

b. Seeing Eye and Hearing Dogs. The OWCP may pay for seeing eye and

hearing dogs, as well as for their training and maintenance costs, on

prescription of the attending physician if this service is required because of

blindness in both eyes or severe deafness (at least 80 percent binaural loss)

resulting from factors of the employment.

c. Change in Locality. Where a physician recommends that an injured

employee visit or move to another climate to alleviate symptoms of the

employment-related condition, the expenses incurred may be authorized if

OWCP finds that such a move is likely to cure, give relief, reduce the degree

or period of disability, or aid in lessening the amount of monthly

compensation. After developing the evidence, the CE should refer the case

file to the DMA for opinion concerning the advisability of such a move.

3-0400-9 Injury or Death While Obtaining Medical Care

9. Injury or Death While Obtaining Medical Care.

a. Benefits Payable. When an employee is injured while traveling to or

obtaining authorized medical care or examination, he or she is entitled to

medical benefits just as if the injury had occurred in the performance of duty.

If an injured employee dies away from home while receiving medical

examination or treatment, the body may be embalmed and transported in a

hermetically sealed casket to the employee's home at OWCP expense even if

death did not result from an accepted injury. If death resulted from a

condition unrelated or questionably related to the accepted condition,

authorization for services should include a request for postmortem

examination.

b. Pathological and Postmortem Examinations. The DMA may authorize

pathological examination of removed tissue at OWCP expense if such

examination is necessary to determine the merits of a claim that has been or

will be filed. If a postmortem examination has not been ordered by the

coroner or local medical examiner, permission for such an examination must

be requested in accordance with the appropriate state law.

c. Autopsy. If an autopsy is authorized, the DMA should specify that it

be conducted by a pathologist or another physician fully qualified to perform

such services and that a complete autopsy protocol must be submitted prior

to payment of the bill. Authorization for this procedure may be given by

telephone, followed by written confirmation or by telegram (where the

medical examiner is overseas). See PM Chapter 2-700 for additional

information concerning autopsies.

3-0400-10 Transportation and Expenses

10. Transportation and Expenses. OWCP will reimburse the cost of transportation

needed for treatment or examination of the claimant for the accepted injury, unless

transportation is furnished by the government. The transportation costs may include

the services of an accompanying nurse or attendant if required (see paragraph 6a(4)

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above). Incidental expenses may also be reimbursed whether or not transportation

is furnished by the Government, but OWCP cannot advance funds to defray travel

and incidental expenses except as noted below.

a. Mode of Travel. Travel should be undertaken by the shortest route,

and if practical, by public conveyance such as bus or subway. If the medical

evidence shows that the employee is unable to use these means of

transportation, the CE may authorize travel by taxi or special conveyance.

Transportation by ambulance may also be authorized if required, and if travel

by air ambulance is indicated, or air ambulance is found to be more

economical and expeditious than ordinary commercial air transportation,

approval may be granted for this service. In all such instances the DMA will

be consulted for advice, by telephone if indicated.

b. Transportation Expenses. Standard Form 1012 and Form CA-1077

shall be sent to the injured employee whenever examination and/or

treatment is authorized. They are used to claim reimbursement for travel

expenses when the government does not furnish transportation. When the

employee must travel to secure authorized examination and/or treatment and

the travel will cost more than one hundred dollars by public transportation, a

Government Transportation Request (GTR), Standard Forms 1169 and 1169a,

may be issued. The claimant should be instructed to return a GTR which is

not used so it can be canceled.

c. Accompaniment While Traveling. If the employee requires a nurse or

an attendant to accompany him or her in securing examination and/or

treatment, this service and associated transportation and incidental costs may

be authorized. Unless a need for other arrangements is demonstrated, he or

she should be instructed to make the return trip as soon as possible so that

no unnecessary expense will be incurred.

d. Incidental Expenses. Charges for child care, pet care, and home

security may be paid when incurred in the course of securing medical services

and supplies. In each case, the record must contain a memorandum

discussing the need for the incidental expenditure and the reasonableness of

the amount claimed.

(1) Necessity and Reasonableness. Incidental expenses shall be

paid to the extent that they are necessary and reasonable. For

example, in a household consisting of the claimant, a child, and a

semi-invalid parent where the claimant must pay for care of the child

and parent while hospitalized, reasonable family care expenses would

be paid. Should additional expenses be claimed, such as a kennel for

the family dog, reasonable kennel charges would be paid only if it were

determined that other arrangements could not be made, such as pet

care by the person staying with the family.

(2) Timing of Expense. Incidental expenses are allowable only

when incurred in the course of securing medical services and supplies.

Therefore, it is necessary to distinguish between expenses connected

with securing treatment and those incurred following treatment.

FECA-PT3 Printed: 08/02/2011

Expenses in the latter category, such as housekeeping costs while the

claimant convalesces at home, are not payable because they are not

required to obtain medical services.

CHAPTER 3-0500 - OWCP Directed Medical

Examinations

Chapter 3-0500, OWCP Directed Medical Examinations

Paragraph and Subject Date Trans. No

Table of Contents 7/11 11-06

1. Purpose 7/11 11-06

2. Statutory Requirements 7/11 11-06

3. Second Opinion Examinations 7/11 11-06

4. Referee Examinations 7/11 11-06

5. Medical Management Application 7/11 11-06

6. Medical Management Codes 7/11 11-06

1. Purpose. This chapter describes the two kinds of OWCP directed medical

examinations, second opinion and impartial referee medical examinations, and the steps

involved in scheduling these examinations.

Other Federal Employees’ Compensation Act (FECA) Procedure Manual chapters also

have relevant guidance pertaining to medical examinations and should be consulted.

Chapter 2-0810, Developing and Evaluating Medical Evidence, discusses the Claims

Examiner's (CE’s) function in evaluating medical evidence and authorizing treatment. It

has specific sections devoted to the decision-making process for obtaining second

opinion and referee examinations.

Chapter 3-0300, Authorizing Examination and Treatment, discusses the circumstances

under which OWCP or, in some instances, the employing agency may authorize medical

FECA-PT3 Printed: 08/02/2011

services and treatment for injured claimants.

Chapter 3-0600, Requirements for Medical Reports, outlines the information that should

be included in all medical reports.

2. Statutory Requirements. The authority to schedule second opinion and referee

examinations is specifically noted in the FECA in §8123, which states:

An employee shall submit to examination by a medical officer of the United

States, or by a physician designated or approved by the Secretary of Labor, after

the injury and as frequently and at the times and places as may be reasonably

required. The employee may have a physician designated and paid by him present

to participate in the examination. If there is disagreement between the physician

making the examination for the United States and the physician of the employee,

the Secretary shall appoint a third physician who shall make an examination.

3. Second Opinion Examinations. The attending physician (AP) is the primary

source of medical evidence in most cases, and the AP is expected to provide a

rationalized medical opinion based on a complete medical and factual background in

order to resolve any pending issues in a case. In certain circumstances, such as where the

AP’s report does not meet the needs of the OWCP, OWCP may schedule a second

opinion examination (SECOP).

a. Determining the Need for Examination. The decision to refer a case for a

second opinion examination rests with the CE, though such an exam may be

recommended by a Field Nurse (FN) or District Medical Advisor (DMA), or

requested by the employing agency. A complete discussion of when a CE should

refer a case for a second opinion examination is found in PM 2-0810-9 and 2-810-

10.

Also, OWCP may send a case file for second opinion review where actual

examination is not needed, or where the employee is deceased.

b. Selection of SECOP Physician.

(1) Physicians selected to perform second opinion examinations

should be administratively qualified in the appropriate branch of medicine.

(a) Where an emotional condition is the only work-related

condition known to be present, a referral can be made to a

psychiatrist or a clinical psychologist (as long as the file contains

no indication that medication for a psychological condition is

being used). Referral to a clinical psychologist may be made even

if the attending physician is a psychiatrist, but not where

psychogenic overlay is felt to be present, as these cases presuppose

a connection between the psychological condition and its physical

manifestation which can best be addressed by a psychiatrist.

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(b) If the issue for determination is the causal relationship

between a workplace injury/factor and a claimed condition or a

claimant’s ability to perform the date of injury position or some

other type of modified work, a referral can be made to a specialist

in occupational medicine, even if the attending physician is an

orthopedist, neurologist or some other specialty. As a sub-

specialty under the Board of Preventive Medicine, occupational

medicine physicians are specialists in the field of workplace

injuries and illnesses and their causal associations. They also

specialize in assessing fitness for duty relevant to the employee’s

work environment.

(2) Second opinion examinations are generally conducted by a

physician selected by a medical referral group that has contracted with

OWCP to provide second opinion medical referrals. The method for

selecting second opinion physicians is more flexible, since a strict rotation

of physicians is not required for this type of examination.

(3) If the medical referral group is unable to schedule the necessary

appointment in accordance with the needs of OWCP, OWCP can use the

Medical Management application for this purpose (see paragraph 5

below).

c. Information Sent to Physician. The physician should be provided with the

following:

(1) Description of the reason(s) for requesting the examination and a

list of questions to be resolved, along with a blank Form OWCP-5 if

appropriate.

(2) Statement of Accepted Facts (SOAF).

(3) Copies of pertinent medical reports from the case record, including

diagnostic test results, if applicable.

d. Information Sent to Claimant and the Properly Authorized Designated

Representative. Once the appointment has been scheduled, the

claimant/representative should be notified. See Donald J. Knight, 47 ECAB 706

(1996) (where ECAB held that OWCP’s failure to notify appellant's authorized

representative of the referral to a second opinion physician effectively denied

appellant's statutory right to have a physician designated and paid by him to be

present and participate in the examination pursuant to 5 U.S.C. 8123). This may

be done by OWCP, or by the contractor on OWCP’s behalf. The claimant and

his or her designated representative should be provided with the following

information:

FECA-PT3 Printed: 08/02/2011

(1) The name and address of the physician to whom he or she is being

referred, as well as the date and time of the appointment.

(2) The claimant's right, under section 5 U.S.C. 8123 of the FECA, to

have a physician paid by him or her present during a second opinion

examination. 20 C.F.R. § 10.320; Esther Velasquez, 45 ECAB 249 (1993)

(ECAB held that by misinforming the claimant of the purpose of the

medical referral, OWCP effectively denied her the right granted by the

FECA, and that OWCP was precluded from relying on the resulting

medical report “before affording appellant the opportunity to exercise this

statutory right.”).

Because a claimant has a right under the statute to have such a physician

attend a second opinion examination, OWCP may not re-characterize an

impartial examination as a second opinion examination in the event it

determines there was no conflict in the medical evidence; however, the

report need not be excluded and may be considered for its intrinsic value.

(3) A warning that benefits may be suspended pursuant to 5 U.S.C.

8123(d) for failure to report for examination.

(4) Information on how to claim travel expenses.

e. The employee is not entitled to have anyone present at the examination

(other than the physician identified in d(2) above), unless the case file or other

rationalized medical evidence establishes the need for someone else in the room,

or OWCP decides that exceptional circumstances exist. However, where an

employee requires an accommodation, such as where a hearing-impaired

employee needs an interpreter, the presence of an interpreter or other individual

will be allowed. Anthony H. Jackson, 53 ECAB 529 (2002) (ECAB held that a

claimant is not entitled to have anyone other than a qualified physician in

attendance at a referral medical examination unless OWCP decides that

exceptional circumstances exist); Ida L. Townsen, 45 ECAB 750, 757 (1994)

(finding that interference by appellant's representative in insisting that he be

present for a medical examination constituted obstruction under section 8123 and

supported suspension of appellant's benefits).

f. Follow-up Action. Using the SOAF (See FECA PM 2-0809 regarding

SOAF requirements) as the framework for his or her opinion, the second opinion

physician should provide a report which contains a clinical history, results of the

examination, results of any testing performed, and a reasoned opinion in response

to the questions posed. A report should be expected within 30 days of the

examination.

(1) If no medical report is received within 30 days from the date of

appointment, the CE or medical scheduler should inquire as to the status

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with the medical referral group and/or the second opinion physician. The

CE or medical scheduler may also follow up soon after the date of the

appointment to verify the claimant’s attendance at the appointment. For a

complete discussion describing the circumstances under which benefits

may be suspended under 5 U.S.C. 8123(d) for failure to attend an

appointment, see PM 2-0810-13 Suspension of Benefits.

(2) Upon receipt of the report, the CE should review the report to

ensure that the physician has adequately addressed the questions posed.

(a) If clarification or additional information is necessary, the

CE should write to the specialist to obtain it, either directly or via

the medical referral group, as appropriate.

(b) Upon receipt of any clarifying information, the CE should

again review the report to ensure that it is complete and responsive

to the questions asked.

4. Referee Examinations. Section 8123(a) of the FECA and section 10.321 of the

implementing regulations provide for the appointment of a referee physician to examine

the claimant and resolve a conflict of medical opinion in a case. This is referred to as an

impartial medical examination (IME). Because this method of resolving conflicts is

provided in the FECA, the probative value of the referee specialist's report is great and

will normally constitute the weight of the medical evidence of record. Y.A., 59 ECAB 701

(2008) (when a case is referred to an impartial medical specialist for the purpose of

resolving a conflict in medical opinion, the opinion of such specialist, if sufficiently well

rationalized and based on a proper background, must be given special weight).

a. Determining the Need for Examination. A difference in medical opinion

sufficient to be considered a conflict occurs when two reports of virtually equal

weight and rationale reach opposing conclusions. See James P. Roberts, 31

ECAB 1010 (1980). The CE makes this determination after weighing the

opinions. See PM 2-0810-6 for an extended discussion on weighing medical

evidence. A complete discussion of when a CE should refer a case for a referee

examination is found in PM 2-0810-11. 20 CFR § 10.321(a).

b. Selection of IME Physician. Unlike selection of second opinion

examining physicians, selection of referee physicians is made on a strict rotational

basis.

(1) OWCP will select a physician who is qualified in the appropriate

specialty and who has had no prior connection with the case.

(2) The Employees' Compensation Appeals Board has placed great

importance on the appearance as well as the fact of impartiality, and only

if the selection procedures which were designed to achieve this result are

carefully followed may the selected physician carry the special weight

FECA-PT3 Printed: 08/02/2011

accorded to an "impartial specialist."

In Leonard W. Waggoner, 37 ECAB 676 (1986), ECAB remanded the

case because the physician who examined the claimant was an associate of

the physician to whom the claimant had been referred. Since the claimant

was told to report to one physician but was ultimately examined by

another, he had no opportunity to object to the choice of examiner. ECAB

did not find that the specialist in this case was in fact biased, or would

have been ineligible on any particular ground. Rather, it found that to give

special weight to a physician not selected in accordance with procedures

would "undermine the appearance of impartiality or would appear to

compromise the integrity of the system for selecting impartial specialists."

ECAB found that the physician was not entitled to the special weight

accorded to a referee specialist because the procedures designed to provide

adequate safeguards against any possible appearance of bias were not

followed.

(3) Physicians in certain roles may not be chosen to act as referees in

specific cases. When a physician is asked to act as a referee specialist, the

medical scheduler should inquire as to the nature of any previous

association with the claimant or the claimant's employing agency.

Physicians who may not be used as referees include:

(a) Those employed by, under contract to, or regularly

associated with Federal agencies. See George W. Coast, 36 ECAB

600 (1985) (ECAB held that although there was no direct evidence

of record substantiating that the physician was previously

connected with the claimant's case, the selection of a physician

involved with fitness-for-duty examinations on behalf of the

employing establishment undermined the appearance of

impartiality).

(b) Physicians previously connected with the claim or the

claimant, or physicians in partnership with those already so

connected (see Raymond E. Heathcock, 32 ECAB 2004 (1981)

(ECAB held that OWCP could not use the report of one physician

to resolve a conflict in medical evidence because he was an

associate of another physician previously connected with the case,

and therefore was not completely independent)).

OWCP (see John Clement, 35 ECAB 959 (1984)).

Note: The mere fact that a physician has conducted a second

opinion examination in connection with the FECA program does

not eliminate that physician from serving as an impartial referee

FECA-PT3 Printed: 08/02/2011

physician in another case.

(4) In a case involving only a mental condition where a conflict exists

between two psychologists or between a psychologist and a physician who

does not specialize in treatment of mental disorders, the referee specialist

chosen to resolve the case may be either a psychiatrist or clinical

psychologist (as long as the file contains no indication that medication for

a psychological condition is being used). In those cases, however, where a

conflict has arisen between a psychologist and a psychiatrist or between

two psychiatrists, the Office will obtain a referee examination from a

psychiatrist. This practice will ensure that the referee physician carries

sufficient weight in cases where a medical doctor has been involved in

creating the conflict, and should also ensure that the full range of issues is

addressed.

(5) In a case involving a physical condition where a conflict exists

with regard to the causal relationship between a workplace injury/factor

and a claimed condition or a claimant’s ability to perform the date of

injury position or some other type of modified work, a referee examination

may be scheduled with an occupational medicine physician, even if one or

both of the physicians with conflicting opinions is not an occupational

medicine physician. As a sub-specialty under the Board of Preventive

Medicine, occupational medicine physicians are specialists in the field of

workplace injuries and illnesses and their causal associations, and they

also specialize in assessing fitness for duty relevant to the employee’s

work environment, they are qualified to provide an opinion on these issues

and may be afforded the special weight provided to referee physicians.

(6) The selection of a physician to perform a referee medical

examination is done by the district office using the Medical Management

application within the Integrated Federal Employees’ Compensation

System (iFECS). This selection process is described in detail in paragraph

5 of this chapter.

(a) The Medical Management application contains the names

of physicians who are Board-certified in certain specialties. The

database of Board-certified physicians used for referee

examinations contains over 30 specialties, including:

cardiovascular disease, dermatology, gastroenterology, internal

medicine, neurology, occupational medicine, osteopathy,

orthopedic surgery, physical medicine and others.

(b) The services of all available and qualified Board-certified

specialists will be used as far as possible to eliminate any inference

of bias or partiality. This is accomplished by selecting physicians

(in the designated specialty in the appropriate geographic area) in

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alphabetical order as listed in the roster and repeating the process

until the list is exhausted.

application, and thereby the rotation, by the District Director, or

his/her designee after verifying that the physician meets the board-

certification requirements for a particular specialty.

(d) A physician may be eliminated from the rotation for the

following reasons, which include, but are not limited to: he or she

is not willing to perform examinations for OWCP; reports have

shown a predictable pattern amounting to bias; he or she

chronically submits inadequate reports in the face of acceptable

questions; reports are consistently submitted late; or he or she has a

signed agreement with OWCP to perform case file reviews.

OWCP may discontinue the use of a physician by properly

updating the Medical Management application and citing instances

(dates, specific case files, etc.) in which bias or inadequacies are

demonstrated. The District Director, or his/her designee, is

authorized to suspend or permanently remove a physician.

(e) Excluded providers are disqualified from serving as referee

physicians (see Chapter 3-0800).

(f) A physician who is not Board-certified may be used if he or

she has special qualifications for performing the examination, but

the scheduler must document the reasons for the selection in the

case record.

(7) Sometimes examination by more than one kind of specialist is

required in order to fully address work-related injuries and any

complications that may be associated with the injuries. If the CE has

identified the need for examination by two kinds of specialists, for

instance an orthopedist and a psychiatrist or clinical psychologist, the

scheduler will arrange two separate examinations without asking either

physician to coordinate the results.

On the other hand, a referral physician who needs to obtain information

from another provider is authorized to make subsidiary referrals as

necessary (for instance, a psychiatrist may refer a claimant to a clinical

psychologist for testing). In this case, the referral physician should submit

a summary report discussing any discrepancies among the physicians'

viewpoints so that questions posed by OWCP are fully answered.

In extremely complex cases, a panel of physicians may be asked to

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examine the claimant and render a collective opinion. The services of

such panels are most easily arranged through medical schools and

hospitals, as these institutions employ specialists in many fields of

medicine. Such referrals are rare.

c. Information Sent to Physician. The physician should be provided with the

following:

(1) Description of the reason(s) for requesting the examination,

including an indication of the conflict and a list of questions to be

resolved, along with a blank Form OWCP-5 if appropriate.

(2) Statement of Accepted Facts (SOAF).

(3) Copy of the complete case file, either in paper or electronic form.

(4) Notice that he or she is the only individual authorized to perform

the requested examination and provide the required report.

(5) Prompt payment billing information, including the code for referee

medical examination or case review.

d. Information Sent to Claimant and Properly Authorized Designated

Representative. Once the appointment has been scheduled, the

claimant/representative should be notified. See Rosita Mahana, 50 ECAB 331

(1999) (ECAB held that by not notifying appellant and her attorney of the identity

of the impartial medical specialist, OWCP deprived her of an opportunity to

present any objections to the selection of Dr. Schwarz as the impartial medical

specialist; and, accordingly, Dr. Schwarz was not properly selected as an impartial

medical specialist and her report could not be used to resolve the conflict of

medical opinion). The claimant and his or her duly appointed representative

should be provided with the following information:

(1) Notice of the existence of a conflict in the medical evidence and

the specific nature of the conflict. Notification should also be included

that the examination is being arranged under the provisions of 5 U.S.C.

8123, which provides the claimant an opportunity to raise any objection to

the selected physician prior to the examination.

(2) The name and address of the physician to whom he or she is being

referred, as well as the date and time of the appointment.

(3) A warning that benefits may be suspended pursuant to 5 U.S.C.

8123(d) for failure to report for examination.

(4) Information on how to claim travel expenses.

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e. The employee is not entitled to have anyone present at the examination

unless OWCP decides that exceptional circumstances exist. For example, an

interpreter may be allowed if a claimant is hearing-impaired. The law does not

provide for participation by a physician of the claimant's choice in a referee

examination (unlike second opinion examinations). 20 C.F.R. § 10.321(b).

f. A claimant who asks to participate in selecting the referee physician or

who objects to the selected physician should be requested to provide his or her

reason for doing so. The CE is responsible for evaluating the explanation offered.

See Miguel A. Munitz, 54 ECAB 217, 221 (2002) (ECAB held that OWCP

properly denied appellant’s request to participate in the selection of the impartial

medical specialist: “appellant's representative merely requested to participate in

the selection of the referee examiner, in an ‘attempt to assure that the claimant

receives an impartial evaluation concerning this schedule award claim.’ The

Board finds that he did not provide a valid reason for participating in the selection

and did not raise a specific objection to the selected physician.”); Terrance R.

Stath, 45 ECAB 412 (1994) (ECAB has recognized that under the OWCP’s

procedures, a claimant is entitled to participation in the selection of an impartial

specialist; however, the claimant does not possess an unqualified right to

participate. The claimant must provide a valid reason for request for participation

at the time the conflict of medical opinion is found.).

(1) Examples of circumstances under which the claimant may

participate in the selection include (but are not limited to):

(a) Documented bias by the selected physician;

(b) Documented unprofessional conduct by the selected

physician;

gynecological examination is required; or

(d) A claimant with a medically documented inability to travel

to the arranged appointment when an appropriate specialist may be

located closer. For instance, if the orthopedic specialist chosen

through the Medical Management application in iFECS is three

hours by automobile from the claimant's home, but an orthopedic

specialist in the nearest large city is only one hour away by

airplane, the latter physician may be chosen if the attending

physician documents that the claimant can not travel for three

hours by automobile.

(e) Simple preference for examination in a particular location

will not be considered a valid reason. See S.W., Docket No. 09-

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1110 (issued February 19, 2010) (ECAB held that appellant did not

present any evidence establishing that the impartial selection was

improper: “Although appellant’s attorney noted that the Office of

the impartial medical examiner was approximately 281 miles from

appellant's residence, the Office indicated that it would reimburse

travel expenses, including the cost of an overnight stay, if

necessary. A simple preference for examination in a particular

location is not considered a valid reason for objecting to an

impartial medical examiner.”).

(2) If the reason is considered acceptable, the scheduler will prepare a

list of three specialists available through the Medical Management

application in iFECS, including a candidate from a minority group if

indicated, and ask the claimant to choose one. This is the extent of the

intervention allowed by the claimant in the process of selection or

examination.

(3) If the reason offered is not considered valid, a formal denial on the

claimant's request, including appeal rights, may be issued if requested.

g. Follow-up Action. Using the SOAF as the framework for his or her

opinion, the referee physician should provide a report which contains a clinical

history, results of the examination, results of any testing performed, and a

reasoned opinion in response to the questions posed sufficient to resolve the

conflict. A report should be expected within 30 days of the examination.

(1) If no medical report is received within 30 days from the date of

appointment, the CE or medical scheduler should inquire as to the status

with the referee physician’s office. The CE or medical scheduler may also

follow up soon after the date of the appointment to verify the claimant’s

attendance at the appointment. For a complete discussion describing the

circumstances under which benefits may be suspended under 5 U.S.C.

8123(d) for failure to attend an appointment, see PM 2-0810-13

Suspension of Benefits.

(2) The CE must refrain from verbal contact to discuss any substantive

issue in the case with a physician who has been engaged to provide a

referee opinion. All such communication regarding these issues should be

in writing.

If a referee medical report is obtained through such substantive telephone

contact with the physician or submitted as a result of such contact, the

referee report must be excluded. See PM 2-0810-12 for further details

regarding exclusion of medical evidence.

The CE may only verify attendance at the appointment and inquire as to

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the status of the submission of the report, and should document that

verification with a CA-110.

(3) Upon receipt of the report, the CE should review the specialist's

report to ensure that it meets the requirements for a referee examination

and that it addresses all issues posed.

(a) If someone other than the selected physician examined the

claimant, the report cannot be used to resolve a conflict in medical

opinion and cannot be afforded special weight. It should be

annotated accordingly, and another referee examination must be

arranged. Moreover, any indication of interference by the

employing agency or claimant's representative will be considered

sufficient to bias the report, which will then not be considered

probative evidence.

(b) If clarification or additional information is necessary, the

CE should write to the specialist to obtain it. Under no

circumstances, however, should the CE telephone the specialist for

elaboration of the report as information obtained in this manner

cannot be considered probative medical evidence and bias may be

inferred as a result, leading to exclusion of the report. See PM 2-

0810-12 for further details regarding exclusion of medical

evidence.

again review the report to ensure that it is complete and pertinent

to the questions asked. When the referee's report is considered

adequate, the CE will take action without review by the DMA,

except where a referee examination was arranged to resolve a

schedule award issue. See PM 2-810-8.k. for further details

regarding DMA review of referee reports relating to schedule

award determinations.

5. Medical Management Application. The Medical Management application in

iFECS, which replaced the Physician Directory System (PDS), allows users access to a

database of Board-certified specialist physicians and is used to schedule referee

examinations and sometimes second opinion examinations if needed. This application

contains an automatic and strict rotational scheduling feature. This application provides

for consistent rotation among physicians and records the information needed to document

the selection of the physician.

a. In 2000, an updated version of the PDS standalone software was placed

into the iFECS system, replacing the previous PDS system. The directory of

medical specialists contains physician from the American Board of Medical

Specialties (ABMS). The ABMS includes the medical boards of the American

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Medical Association (AMA) that certify candidates in their respective fields of

specialization.

OWCP recognizes osteopathic doctors (D.O.) as physicians within the meaning of

the Act. As such, OWCP also accords special weight to their opinions as

impartial referee physicians, provided they are Board-certified with the American

Osteopathic Association (AOA).

b. Selection of a referee physician should be made only through the use of

the Medical Management application (absent exceptional circumstances discussed

below), and CEs may not dictate which physician will serve as a referee

examiner.

However, where exceptional circumstances exist (such as when an esoteric

specialty is required, or the Medical Management application does not contain

any physicians of the required specialty within a 200 mile radius), scheduling

outside of the Medical Management application may be appropriate. If this

occurs, the scheduler should consult an appropriate directory of medical

specialists to obtain names of suitable physicians for referral. Documentation

outlining the rationale for this decision must be placed in the case file, and the

decision must be approved by a Supervisory Claims Examiner or higher level

authority.

If an examination needs to be rescheduled with a prior referee examiner in

accordance with a remand order or where follow-up is necessary, scheduling

outside of the strict rotational guidelines may also be necessary. In these more

obvious instances, documentation must still be placed in the case file but approval

by a Supervisory Claims Examiner or higher level authority is not required.

c. When the medical scheduler inputs a claim number, the claimant’s home

zip code is automatically loaded. The medical scheduler then chooses the type of

examination (second opinion or referee) and the specialty. Information regarding

the next physician on the roster, based on medical specialty and zip code, appears

on the screen and remains on the screen until the appointment is scheduled or

until the physician is bypassed. The entire roster of physicians is invisible to the

medical scheduler, as he or she can only see and update the information pertaining

to the selected physician until a decision is made to schedule the appointment or

bypass the physician. See paragraph 6 of this chapter for a complete discussion

on the reasons for bypassing a physician.

d. The universe of physicians included in the search and available for referee

scheduling is based on the specialty chosen and the claimant’s home zip code.

Physicians are presented to the medical scheduler in alphabetical order, except

that any physician in the universe that has been either bypassed or had an

appointment scheduled will be at the bottom of the list based on the date of that

last contact. Presentation of physicians is based on the last contact, such that the

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physician in that universe who was either bypassed by the office or had an

appointment scheduled most recently will be at the bottom of the list.

e. The medical scheduler will contact the physician presented by the Medical

Management application to ascertain whether the necessary appointment can be

scheduled in a timely manner.

f. If an appointment cannot be scheduled in a timely manner (or for some

other reason such as a conflict, the physician is of the wrong specialty, etc.), the

scheduler will update the application with an appropriate bypass code. Upon

entering a bypass code, the Medical Management application will present the next

physician in the universe based on specialty and zip code. See paragraph 6 of this

chapter for more explicit information pertaining to the use of bypass codes.

g. If the physician agrees to schedule the appointment, the scheduler inputs

the appointment date and time into the Medical Management application. The

application saves the appointment information and prompts the scheduler to

prepare form ME023, Appointment Notification Report, for imaging into the case

file.

The ME023 report can only be generated through the Medical Management

application and serves as documentary evidence that the referee appointment was

scheduled through the use of the rotational system in the Medical Management

application. The medical scheduler should image a copy of the ME023 into the

case file to substantiate that the rotational system was used to select the physician.

In the event the report is not included in the file at the time of the referral and an

issue is raised concerning the IME selection later in the appeal process, a copy of

the original ME023 may be reproduced at a later date; no adjustments can be

made to the initial information, and it will include the original date.

h. If all physicians presented are bypassed and there are no physicians

available within that zip code range, the Medical Management application

prompts the medical scheduler to select a range of miles for selection of another

zip code. The scheduler incrementally chooses zip code ranges so that the closest

available appointment to the claimant’s home zip code can be scheduled.

The Medical Management application sets 200 miles as the outer limit for zip

code selection. If the scheduler reaches the 200-mile mark and still cannot find a

physician, a print screen from the application showing that there are no physicians

within that range should be placed in the case file. The scheduler will then need

to use an alternative method for scheduling the examination as outlined in 5(b) of

this chapter.

i. If a scheduled appointment has to be cancelled or rescheduled for any

reason, the file should be appropriately and clearly documented.

6. Medical Management Codes. The Medical Management application has

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numerous codes to display the disposition of physicians and appointments.

If a physician cannot or will not schedule an examination, he or she must be bypassed in

the Medical Management application so that the next physician in the rotation is available

for scheduling. Various codes are used to document the reasons for not scheduling an

examination with a physician in the rotation.

Most codes are stand-alone codes and do not require any rationale beyond their meaning

as outlined in this chapter. However, three codes, code B (Busy), code L (Location), and

code O (Other), do require a note explaining the reason for entry of the code. The note is

entered directly into the Medical Management application, without any requirement that

the imaged file be documented. Bypass notes entered must be sufficiently detailed to

explain the reason the physician was bypassed (e.g. a note like “pass” is not sufficient),

and the use of local abbreviations should be avoided. Finally, while notes are not

mandatory for all codes, if the scheduler enters a note, it should be applicable and

germane to the bypass code used.

Code A - Appointment Cancelled. This code is used when an appointment has been

cancelled by either the physician or OWCP. This code is not a bypass code option but

can be used in other portions of the Medical Management application.

Code B - Busy. This code is used when the physician cannot schedule an appointment in

a reasonable amount of time (usually within 60 days) or is on extended leave or a leave of

absence. A note is required to further explain usage of this code, e.g. “physician is on

medical leave of absence – unknown return date.” This code should NOT be used if the

telephone line is busy or if the medical receptionist indicates the physician is too busy at

the moment to take the call.

If a physician will be on a defined period for a leave of absence longer than 60 days, the

user should annotate the physician’s record in the Medical Management application in

iFECS as appropriate. This will ensure that the physician does not appear in the rotation

for the leave of absence period but will again appear in rotation once the leave of absence

has ended.

Code C - Conflict. This code is used if the physician, or his/her associate, has a previous

connection with the claim. This also includes physicians performing fitness for duty

exams for the employing agency.

Code D – Physician does not accept DOL patients. This code is used if the physician

will not accept any Department of Labor (DOL) cases, will not do IMEs, will not accept

workers’ compensation cases, or is not willing to perform examinations for OWCP.

If a physician will not accept DOL or OWCP cases for medical examinations, the

physician’s record in the Medical Management application in iFECS should be updated

so that the physician no longer appears in the rotation.

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Code E - Excluded/Lost license. This code is used if a physician is an excluded

provider or has lost required licensing. This code is not a bypass code option but can be

used in other portions of the Medical Management application.

Code L - Location is too far for claimant. This code is used when the physician’s

office is too far for the employee to travel, or the claimant may be medically unable to

travel long distances to report for examination. A note is required to further explain

usage of this code, since distance to travel is accounted for in the rotational presentation

of physicians in the Medical Management application.

Code M - Physician moved out of zip code area. This code is used when the physician

is no longer at the address shown in our database. The medical scheduler should attempt

to obtain current contact information to update the physician address in the Medical

Management application. If the physician is still within the same zip code as the address

in the Medical Management application, the address can be updated and the appointment

scheduled.

Code O - Other. This code is used when none of the other bypass reasons are

applicable. This code is appropriate to use when no one answers the phone (e.g. “phone

rings continuously with no answer”) or the phone number has been disconnected (e.g.

“phone disconnected/no other contact number noted”). A note is required to explain

usage of this code, and code O should not be used if there is another appropriate code.

Code O is also appropriate if the medical scheduler must leave a message. If a message

must be left, the medical scheduler should note the name of the person who was

contacted or that a message was left on a voice mail. While waiting for a return call, the

appointment with that particular physician should be put into a “pending” status. The

scheduler should allow the physician’s office a minimum of two business hours for a

return call (as determined by usual physician business hours). If the physician’s office

does not call back within this period of time, the physician can be bypassed with the O

code and another physician can be contacted. When the scheduler removes the “pending”

status, the bypass note should be updated with an annotation that no call back was

received. If a call back was received, and it was determined that the appointment could

not be scheduled for some other reason (related to another bypass code), the record

should be updated accordingly.

If a physician previously bypassed as non-responsive contacts the OWCP medical

scheduler prior to the scheduler finalizing an appointment with another physician,

continued efforts to arrange an examination with the second physician should cease and

the appointment should be scheduled with the previously bypassed physician, as he or she

was actually earlier in the rotation of physicians. If this occurs, the note should be

updated accordingly when the appointment is scheduled.

Code S – Subspecialty. This code is used if the case requires a different subspecialty, or

if the physician does not evaluate the specific body part or extremity. For instance, the

physician will only perform exams for back conditions but the claimant has an upper

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extremity injury.

Code U - Physician in use by another user. This code is used when the physician is in

use by another user. It is not available as a bypass option; rather, it is automatically

updated by the Medical Management application when the next physician in the rotation

is currently in use or in pending status (being contacted for an appointment) by another

user.

CHAPTER 3-0600 REQUIREMENTS FOR

MEDICAL REPORTS

TABLE OF CONTENTS

Paragraph and Subject Date Trans.No

Table of Contents 09/96 96-15

1. Purpose 10/90 91-02

2. Reports of Disability and Impairment 10/90 91-02

3. Statement of Accepted Facts (SOAF) 10/90 91-02

4. Questions for Response 10/90 91-02

5. Form of Medical Reports 10/90 91-02

6. Content of Medical Report 10/90 91-02

7. Criteria 10/90 91-02

8. Specific Conditions 10/90 91-02

09/94 94-42

09/95 95-39

9. Partial Disability 12/91 92-07

10/90 95-04

Exhibits

1 Attending Physician's Report

Form CA-20 12/94 95-04

Page 1-2

Page 3

2 Attending Physician's Supplemental

Report, Form CA-20a 12/94 95-04

Page 1-2

3 Duty Status Report, Form CA-17 12/94 95-04

Page 1-2

4 OWCP Hearing Loss Medical

Requirements 09/96 96-15

5 Outline for Otologic Evaluation, 09/94 94-42

Form CA-1332

Page 1-2

Page 3-4

6 Calibration Requirements for

Accreditation of an Audiological

Facility by the Professional

Services Board 09/94 94-42

7 OWCP Medical Examination

Requirements

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in Asbestos Disease Cases 12/94 95-04

8 Roentgenographic Interpretation 12/94 95-04

Form CM-933

Page 1

Page 2

9 Carpal Tunnel Cross-Sectional View

(Link to Image) 12/94 95-04

3-0600-1 Purpose

1. Purpose. The Office relies on written medical reports to justify awards for

compensation, support payment of medical expenses, and monitor the quality of care

being provided. This chapter will detail the type of information needed to render

proper determinations for the medical issues in each case.

3-0600-2 Reports of Disability and Impairment

2. Reports of Disability and Impairment. Reports are submitted by attending

physicians, consultant (second opinion) specialists, and referee physicians. Each

report may address one or more topics pertaining to the claimant's medical status.

Whatever the format or source of a report, the information provided in it must be

sufficiently clear and detailed so that claims and medical reviewers are certain of the

physician's findings, conclusions,

and opinions.

Under the FECA, impairment is defined as the anatomical or functional loss or

reduction of a function of an organ of the body in reference to the activities of

normal life; it pertains solely to the claimant's medical condition. Disability is

defined, on the other hand, in terms of the claimant's ability to perform the duties of

his or her job.

3-0600-3 Statement of Accepted Facts (SOAF)

3. Statement of Accepted Facts (SOAF). Where a medical opinion is needed to

resolve an issue in a case, the file is referred to the Medical Unit with a list of

questions (see paragraph 4 below). An SOAF usually accompanies the case and

provides the factual background for the physician's opinion. Only where the Claims

Examiner (CE) needs general information, for instance about the course of a disease,

will an SOAF not be included.

a. Contents. All SOAFs should include the information listed in items (1)

through (6); depending on the issue to be resolved, the information shown in

items (7) though (10) will be included as well:

(1) The claimant's name and age;

(2) The employer and the job held at the time of injury;

(3) Mechanism of injury;

(4) Conditions claimed or accepted;

(5) Work history since the injury, including the date

the claimant stopped work and returned to either light or regular duty;

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(6) A description of medical treatment since the injury, including

dates of treatment and names of physicians, and if relevant what

diagnostic tests were conducted (physicians' findings and conclusions

should not, however, be discussed in the SOAF);

(7) Relevant medical history;

(8) Specific description of injury or exposure factors, particularly in

cases involving occupational disease;

(9) The claimant's hobbies or activities outside of work;

(10) Physical or mental demands of claimant's regular or light duty

job, or of light duty job offered.

Detailed instructions for CEs concerning the preparation of SOAFs are

contained in PM Chapter 2-809.

The CE is responsible for ensuring that the SOAF is correct, complete,

unequivocal, and specific. When the DMA, second opinion specialist or

referee physician renders a medical opinion based on an SOAF which is

incomplete or inaccurate or does not use the SOAF as the framework

in forming his or her opinion, the probative value of the opinion is

seriously diminished or negated altogether.

3-0600-4 Questions for Response

4. Questions for Response. Files referred to the Medical Unit

will contain a list of question composed by the CE for response by the physician

(DMA, second opinion or referee) to answer. In reviewing case files, the DMA should

ensure that he or she addresses each of the questions posed, preferably in the order

given, and that the response is:

a. Complete and accurate in addressing all of the questions posed and in

addressing them thoroughly. In some instances the DMA may identify

medical issues which the CE has not addressed. It is perfectly appropriate to

discuss such issues and provide information in addition to what the CE has

requested as long as medical rather than adjudicatory questions are the

subject of the discussion.

b. Responsive to the material provided in the SOAF. If the physician

whose reports are under review has based his or her opinion on other factual

material, the DMA should take account of this in reaching an opinion.

c. Well rationalized in discussing the opinion reached. Because the quality

of the Office's adjudicatory functions depends heavily on well reasoned

medical evidence, it is very important to provide clear rationale for the

opinion given.

d. Neutral with respect to adjudicatory issues. It is not appropriate for

the DMA to offer opinions as to whether a case or medical condition should be

accepted. Doing so may adversely affect the outcome of the case since it

may suggest bias to a later reviewer.

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3-0600-5 Form of Medical Reports

5. Form of Medical Reports. The DMA will be expected to review, interpret, or

evaluate a variety of medical reports ranging from simple form reports to detailed

narrative reports (it should be noted that the use of an OWCP form is never required

in making reports). Descriptions of OWCP forms are as follows:

a. Form CA-16, Form CA-20, and Form CA-20a, Attending Physician's

Report. An initial or preliminary report may be submitted on either Form CA-

16 (Exhibit 1, Chapter 3-300 (Link to Image)) or Form CA-20 (Exhibit 1 Pages

1-2( Link to Image); Page 3 (Link to Image)), while a supplementary report

may be submitted on Form CA-20a (Exhibit 2 (Link to Image)). A completed

Form CA-16 or CA-20 represents sufficient medical evidence for adjudication

of most traumatic injury claims, although additional evidence in narrative

form may be required to justify payment of continuing benefits.

b. Form CA-17, Duty Status Report. The CA-17 (Exhibit 3 (Link to

Image)) is used by the employing agency to obtain information from the

attending physician about the claimant's work restrictions. A copy of the form

may be sent to OWCP to aid in evaluating the extent of disability remaining.

Reports submitted by the employing agency generally do not address all

pertinent issues such as the causal relationship between current disability and

factors of Federal employment. Therefore, these reports are usually

considered as supplemental information although some narrative fitness-for-

duty reports may be sufficiently probative in and of themselves.

c. Narrative Report. A narrative medical report may be required if

disability continues or complex issues such as a pre-existing medical condition

are present. In addition, narrative reports are necessary in almost all

occupational disease cases. In any case where the injury causes disability for

work for an extended period or requires lengthy treatment, reports describing

the clinical course, prognosis, and recommendations for further medical care

must be furnished as needed.

3-0600-6 Content of Medical Report

6. Content of Medical Report. Regardless of the form a medical report takes, the

following information will usually be required:

a. Dates of examination or treatment;

b. Clinical history given to the physician;

c. Detailed description of physical findings;

d. Results of any x-ray or laboratory tests;

e. Diagnosis;

f. Prognosis;

g. Description of impairment, if any;

h. Specific limitations for work;

FECA-PT3 Printed: 08/02/2011

i. Clinical course of treatment followed;

j. The physician's reasoned opinion as to the relationship between the

condition found and factors of Federal employment. (Causal relationship is

discussed in PM Chapter 2-805.)

In addition, a detailed description of the employee's work tolerance limitations

is required in any case where the issue is the claimant's ability to return to

duty, and a detailed description of anatomical impairment in accordance with

the AMA Guides is required in any claim for schedule award.

3-0600-7 Criteria

7. Criteria. Guidelines for weighing the value of medical reports are provided in

PM Chapter 2-810. The Office uses the following criteria in evaluating medical

opinions:

(1) Physician's Qualifications. The opinion of a specialist in the

appropriate field of medicine often carries greater weight than the

opinion of a non-specialist or a specialist in an unrelated field. The

opinion of a Board-certified specialist or a specialist of professorial

rank will carry added weight.

(2) Medical Rationale. Opinion supported by a medical explanation

is required in most cases.

(3) Accuracy and Completeness. The factual and medical

background reflected in the report must be correct and complete in

accordance with the facts of the case and the medical information

reflected in other reports in file.

(4) Comprehensiveness. A comprehensive report is one which

reflects that all testing and analysis necessary to support the

physician's conclusions have been performed.

(5) Consistency. The physical findings must substantiate the

medical opinion.

(6) Decisiveness. Opinions containing unclear or vague language

can be characterized as equivocal, speculative or conjectural. Terms

such as "could", "may", or "might be" indicate speculation and/or

equivocation and are assigned less probative value than positively

expressed medical opinions. The term "probably" is considered less

speculative than the above terms and therefore has greater probative

value.

The DMA should render his or her opinion using the Statement of Accepted Facts

(SOAF), which the CE prepares (see Chapter 3-500 for a discussion of the SOAF).

The opinion should be based on the medical evidence of record (except for any

reports annotated with the word "excluded" because the evidence which they contain

was improperly obtained.) The DMA should avoid commenting on legal issues when

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rendering a medical opinion. If the DMA disagrees with the opinion of the treating

physician, a clear and thorough medical explanation must be included.

3-0600-8 Specific Conditions

8. Specific Conditions. OWCP has developed checklists for use by claimants and

their official superiors in order to better identify and gather the information required

to support a claim for occupational disease. These checklists address the following

conditions: hearing loss, asbestos, coronary/vascular conditions, skin diseases,

pulmonary disease other than asbestos, psychiatric illness, and carpal tunnel

syndrome. A general checklist is also available for use in claims for occupational

diseases not enumerated above.

Occupational disease claims in general are discussed in PM Chapter 2-806. The

following guidance is provided with respect to specific medical conditions

encountered in OWCP claims:

a. Hearing Loss. Refer to "Medical Management of Claims under the

FECA" for a discussion of development of such cases. It is generally accepted

that hearing loss may result from prolonged exposure to noise levels above

85 decibels. Acoustic trauma may, however, result from decibel levels below

85 decibels if exposure is sufficiently prolonged. OWCP therefore does not

require that the claimant show exposure to injurious noise in excess of 85

decibels as a condition to approval of the claim.

(1) After obtaining all pertinent factual evidence, the CE will

prepare a Statement of Accepted Facts. Unless the case file already

contains a reliable medical report which fully meets OWCP

requirements, the CE should refer the claimant for audiological

evaluation and otological examination which addresses the relationship

of any hearing loss to the employment and the degree of any

permanent impairment.

The audiological evaluation and the otological examination are to be

performed by different individuals as a method of evaluating the

reliability of the findings through independent observations. If

possible, the two consultations should occur on the same day. The

usual information sent to consultants, as outlined in PM 3-500.3c,

should be forwarded to both the audiologist and otolaryngologist.

(2) The audiological testing is to be performed by persons

possessing certification in audiology from the American Speech-

Language-Hearing Association (ASHA), or State licensure as an

audiologist. The audiological testing should precede the visit to the

otolaryngologist since the latter should have the audiological findings

at the time of the examination. The audiological examination should

be conducted in accordance with OWCP requirements, which are

described in Form CA-1087 (Exhibit 4).

(3) The medical examination should be performed by an

otolaryngologist certified (or eligible for certification) by the American

Board of Otolaryngology. The physician should be instructed to

conduct additional tests or retests in those cases where the initial tests

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were inadequate or there is reason to believe the claimant is

malingering. Form CA-1331 and Form CA-1332 can be used to obtain

the required report.(Exhibit 5) Pages 1-2 (Link to Image); Pages 3-4

(Link to Image))

(4) Audiological equipment used for testing must meet the

calibration protocol embodied in the Professional Services Board

Manual of the ASHA (see Exhibit 6). Each audiologist or physician who

conducts hearing tests must certify that at the time of examination the

equipment used for testing met the standards for accreditation of an

audiological facility by ASHA (ANSI S 3.6 (1969) and 3.1 (1977),

respectively).

(5) Where the employee is deceased, the following procedures are

to be followed according to the stage of development of the medical

evidence:

(a) Where an audiogram meeting the requirements set forth

in Form CA-1087, either alone or in conjunction with

audiograms that do not meet OWCP requirements, appears in

the file, the audiogram may be used as the basis of an award if

it is medically determined to be internally consistent (the

various measurements of the components of hearing are in

substantial agreement) and the evidence shows a causal

relationship between the hearing loss and employment.

(b) Where no audiogram meets the requirements of Form

CA-1087, an audiologist should review all audiograms in the

case to ascertain whether they are internally consistent with

each other and whether the hearing loss was causally related to

employment. If so, an appropriate audiogram should be

selected as the basis for an award. If not, every effort should

be made to determine an equitable award. Where an award is

made based on evidence which does not fully meet the OWCP's

requirements, the CE should prepare a detailed memorandum

to the file which explains how the award was determined. Such

decisions should be signed at the level of the Senior CE or

above.

(6) The DMA calculates the percentage of hearing loss using Form

CA-51 (see Exhibit 3 of PM 3-700 (Link to Image,)) if a schedule award

is at issue. The DMA provides opinion regarding the causal

relationship between any hearing loss and the employment and

verifies the calculations of the audiologist.

b. Asbestos-Related Diseases. Refer to "Medical Management of Claims

under the FECA" for a discussion of development of such cases. It is accepted

that asbestos- related disease may result from occupational exposure in

excess of two fibers/cc (moderate or heavy) during the course of Federal

employment, or the presence of asbestos dust on work surfaces, even if

invisible.

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(1) After obtaining all pertinent factual evidence, the CE should

consider referral to a pulmonary specialist.

(a) If the level of exposure indicated above has been met

and a medical report indicates the possible existence of an

asbestos-related abnormality, such as X-ray report of pleural or

parenchymal abnormality or report of pulmonary fibrosis, the

CE should prepare a Statement of Accepted Facts and arrange

for referral of the claimant to a pulmonary specialist for

complete evaluation in accordance with the requirements

shown in Exhibit 7, OWCP Medical Examination Requirements in

Asbestos Disease Cases.

(b) If the level of exposure indicated above has been met

but no medical report indicates the possible existence of an

asbestos-related abnormality, the claimant shall be instructed

to arrange for submission of a current medical report from his

or her treating physician which meets all of the requirements

shown in Exhibit 7, OWCP Medical Examination Requirements

for Asbestos Disease Cases. If the submitted report satisfies

OWCP requirements and the case is accepted, the cost of the

examination is reimbursable.

In addition to the usual materials sent to consultants (see PM 3-

500.3), the physician selected should be sent copies of Form CM-933

(Exhibit 8, Page 1 (Link to Image), Page 2 (Link to Image)) and the

job description.

(2) Where the employee is deceased, the CE should evaluate the

available medical evidence for completeness and refer the file for

medical evaluation (with Statement of Accepted Facts) to a pulmonary

specialist.

(3) The DMA or consultant acting in that capacity, preferably a

Board-certified pulmonary specialist, should review the report once the

CE determines that it is complete. The medical specialist should be

asked to consider the following issues:

(a) Diagnosis. Are the laboratory and physical

findings adequately supportive?

(b) Work-Relatedness. Has Federal occupational exposure

contributed to development of diagnosed conditions by direct

cause, aggravation, acceleration or precipitation?

percent of pulmonary impairment is indicated?

(d) Disability. Is the evidence sufficient to allow a

determination of the extent and degree of disability for normal

work (current or last) as a result of the diagnosed condition? Is

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the disability partial or total, temporary or permanent?

(e) Treatment. Is the recommended treatment appropriate?

(f) Follow-up. When should the next pulmonary evaluation

be performed?

(g) Employment. If the claimant is still employed and

exposed to asbestos, should employment continue based on

current medical findings, medical knowledge, and documented

working conditions?

c. Carpal Tunnel Syndrome. This condition involves the compression of

the medial nerve between the longitudinal tendons of the wrist musculature

and the transverse superficial carpal ligament along the palmer aspect of the

wrist (see Exhibit 9 (Link to Image)). Symptoms resulting from this

compression include pain, numbness, tingling, and weakness of the affected

hand (usually the dominant one, though bilateral involvement does occur).

Causes which may be work-related include constant exertion and/or repetitive

motion with the wrist flexed or extended against resistance, and acute

trauma. The medical report should contain clear evidence that the disease is

present. Among the clinical findings are:

(1) Phalen's Sign. This test is positive if maintenance of forced

hyperflexion for one minute precipitates pain and paresthesia.

(2) Tinel's Sign. This test is positive if tapping over the medial

nerve at the wrist produces pain.

(3) Neurological Abnormalities. These include decreased sensation

over the palmar aspect of the end joints of the same three and one

half digits and atrophy of the thenar eminence in severe cases.

(4) Decreased nerve conduction velocity (NCV) as measured during

nerve conduction test. The test results should include an evaluation as

to whether the velocities obtained are normal or not.

(5) Decreased muscle motor activity as measured by

electromyography (EMG). The test results should clearly indicate

whether the results are within normal limits or are abnormal. An

opinion as to the cause of the abnormality may also be present.

3-0600-9 Partial Disability

9. Partial Disability. When employment-related injury or disease permanently

prevents a return to regular duties, the Office and the employing agency work

together to reemploy the claimant within his or her work restrictions if possible. If

not, OWCP will offer rehabilitation services to the employee with the goal of

reemployment in the general work force.

a. Loss of Wage-Earning Capacity (LWEC). The CE monitors medical

reports to determine the extent of disability resulting from an employment-

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related injury or disease. When an attending physician's report indicates the

claimant is no longer totally disabled for all work, the physician is sent Form

CA-1302, Request for Medical Progress Report (or narrative equivalent)

and/or Form OWCP-5, Work Tolerance limitations. When this information is

received, the DMA will review it in conjunction with the description of the

position under consideration in order to determine the claimant's ability to

perform the duties involved, if that position has been identified by using the

Dictionary of Occupational Titles (that is, the position is not one which has

actually been offered to the claimant).

Occasionally the DMA will be asked to complete the Form OWCP-5 based on

the examining physician's findings. In doing so, the DMA should consider any

disability which existed prior to the injury as well as any disability resulting

from the employment injury. Subsequently acquired conditions unrelated to

the injury are excluded from consideration in determining the claimant's

LWEC but are included when considering suitability of an offered position.

b. End of Schedule Awards. As with disability, permanent impairment

does not always result in a loss of wage-earning capacity. In some cases,

however, the claimant cannot return to the kind of work performed at the

time of injury, and when this happens, compensation may be awarded based

on the claimant's LWEC. Prior to the expiration of the schedule award, the CE

may request a current medical report to determine whether a claimant has

any LWEC due to the employment injury. To make a proper determination,

the DMA must review the claimant's job description, including its physical

requirements, and compare the claimant's current work tolerance limitations

with the position description.

3-0600 Exhibit 1: Attending Physician's Report, Form CA-20

Page 1-2 (Link to Image)

Page 3 (Link to Image)

3-0600 Exhibit 2: Attending Physician's Supplemental Report, Form CA-20a

Pages 1-2 (Link to Image)

3-0600 Exhibit 3: Duty Status Report, Form CA-17 (Link to Image)

3-0600 Exhibit 4: OWCP Hearing Loss Medical Requirements

OWCP HEARING LOSS MEDICAL REQUIREMENTS

Each employee should be seen for audiological and otological examination. The

audiological testing should precede the visit to the otologist; the otologist should

have the audiological findings at the time of the examination; and, to the extent

possible, these two consultations should occur on the same day. It is also required

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that the audiological and otological examinations be performed by different

individuals.

Any tests administered as part of an audiological battery must be conducted by a

person possessing certification in audiology from the American Speech-Language-

Hearing Association (ASHA) or State licensure as an audiologist. The medical

examination must be performed by an otolaryngologist certified (or eligible for

certification) by the American Academy of Otolaryngology. All tests comprising the

battery administered in the audiological evaluation must be performed in an

environment meeting the specifications of ANSI S3.1 (1977). Facilities which are

accredited by the Professional Service Board of the ASHA meet this requirement.

Testing equipment must be calibrated in accordance with the protocol contained in

the accreditation manual of ASHA's Professional Service Board (ANSI S3.6-1969).

Audiometric tests must include the following:

1. Pure-tone air conduction thresholds should be obtained for each ear at 500,

1000, 2000, 3000, 4000, 6000 and 8000 Hz. Bone conduction thresholds should be

obtained for the specified frequencies from 500 to 4000 Hz, inclusive. Appropriate

masking should be employed as necessary and the use of masking should be

denoted on the audiogram. The symbols used in recording thresholds should be in

accordance with the most recent ASHA recommendations.

2. Impedence audiometry should be done on both ears as a means of determining

the reliability of air-bone conduction threshold relationships and for any contribution

it might otherwise make to differential diagnosis by the physician.

3. Speech reception thresholds for each ear should be established, using test

procedures and spondaic words which conform to guidelines (ASHA Committee on

Audiometric Evaluation, 1979). Standardized recorded materials should be used

rather than live voices.

4. Monaural discrimination scores should be obtained; masking should be used when

necessary. Standardized recorded word lists should serve as the stimuli and the

discrimination scores for the full list should be reported for each ear.

Reports must include, as appropriate:

1. Date and hour of examination.

2. Date and hour of employee's last exposure to loud noise. (If the employee was

exposed to noise within the last 16 hours, do not proceed with testing.)

3. History of injury.

4. The physician's rationalized medical opinion regarding the relation of the hearing

loss to employment-related noise exposure.

5. The physician's recommendation for treatment.

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6. A certification must accompany each audiological battery indicating that

instrument calibration and the environment in which the tests were conducted met

the accreditation standards of the Professional Services Board of ASHA (ANSI S3.6

(1969) and S3.1 (1977), respectively). A copy of the calibration standards are

attached for your convenience.

7. A statement commenting on the reliability of the tests.

3-0600 Exhibit 5: Outline for Otologic Evaluation, Form CA-1332

Pages 1-2 (Link to Image)

Pages 3-4 (Link to Image)

3-0600 Exhibit 6: Calibration Requirements for Accreditation of an

Audiological Facility by the Professional Services Board

CALIBRATION REQUIREMENTS FOR ACCREDITATION OF AN

AUDIOLOGICAL FACILITY BY THE PROFESSIONAL SERVICES BOARD

7.3.4. Calibration: The program shall establish and follow

7.3.4.1. The program shall keep an accurate record of all

audiometric calibrations performed. The record

shall include at least:

a. Type of calibration--biological, electroacoustic,.

b. Date performed.

C All meausurements obtained.

d. Name of observer.

e. Equipment calibrated (make, model,serial#).

f. Calibration equipment used (make, model,

serial#).

7.3.4.2. Diagnostic audiometers and/or audiometers used in

fixed locations shall meet ANSI S3.6-1969

specifications for wide-range audiometers and shall

be calibrated according to the following schedule:

A Daily: A brief biological check of the

audiometer to ensure proper operating order shall

be made each day the audiometer is in use.

B Monthly:

(1) A detailed biological check of the

audiometer which includes a careful listening

test of earphones and bone vibrator shall be

performed to ensure that the audiometer

displays no evidence of:

(i) Cross talk.

(ii) Signal distortion.

(iii) Abnormal noise.

(2) An electroacoustic calibration check of

non-solid-state audiometers shall be made

once a month which includes at least the

following measurements:

(i) The accuracy of the sound presure

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levels for all pure tones in both

earphones.

(ii) The accuracy of the sound pressure

levels for all masking noises in both

earphones.

(iii) The accuracy of the sound pressure

levels for speech signals in both

earphones.

(iv) The accuracy of the sound pressure

levels for speech signals in all sound field

loudspeakers.

c. Quarterly: An electroacoustic calibration check

of solid-state audiometers shall be made once

every three months which includes at least the

measurements specified in section

7.3.4.2.(2)(i)through (iv).

d. Annually: An electroacoustic calibration check

of all audiometer shall be made every 12

months which includes at least the following

measurements:

(1) The accuracy of output levels for all pure

tones in bone vibrator(s).

(2) The accuracy of the frequency

calibration for pure tones.

(3) The accuracy of rise/decay time for all

pure tones.

(4) Harmonic distortion for pure tones.

(5) Signal-to-noise ratio for all outputs.

(6) Accuracy of attenuator linearity.

(7) Accuracy of signal parameters utilized in

special diagnostic tests, including

impedance/admittance.

(8) Freedom from shock hazard.

3-0600 Exhibit 7: OWCP Medical Examination Requirements in Asbestos

Disease Cases

OWCP MEDICAL EXAMINATION REQUIREMENTS IN ASBESTOS DISEASE CASES

1. Occupational History. Chronological summary of the individual's job history

which includes a description of the frequency, degree, and duration of occupational

exposures to asbestos with emphasis on exposure in Federal civilian employment,

but which includes exposure in non-Federal employment. Include other dusts or

toxins and any non-occupational exposure.

2. Medical History. Chronological summary which includes references to any

previous injuries or illnesses, pulmonary problems and the development of

pulmonary symptoms. Summary of pulmonary symptoms. Complete smoking

history. Family medical history.

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3. Physical Examination. To include description of all the following:

a. General appearance and performance.

b. Sex, age, height and weight.

c. General examination denoting the presence or absence of cyanosis,

clubbing, nicotine stains, edema, hepatomegaly, ascites and other signs

ascribable to the pulmonary and cardiovascular systems.

d. The pattern and rate of claimant's breathing (presence and degree of

dyspnea, etc.); the presence of any exertional changes.

e. Results of cardiac examination.

f. The results of chest examination, including configuration, findings on

percussion and ausculation (i.e., the presence or absence of rales and/or

other abnormal sounds).

4. Chest X-rays and CAT Scans. Minimum of AP, lateral and R and L oblique

views. A full size x-ray shall be taken under the supervision of a Board-certified

radiologist and read by either a Board-certified radiologist or pulmonary specialist.

This reading must include a description of the quality of the film and all radiographic

findings. The examining physician will also review the film for these same purposes.

The x-ray interpretation must include a description of any abnormality or pathology

present with special attention given to evidence of pulmonary hypertension, fibrosis,

carcinoma, or mesothelioma. If any abnormality or pathology is present, the

description must include the following information:

a. Presence or absence of opacities described by type, size, shape,

distribution and profusion.

b. Presence or absence of plural thickening, plaques or calcification, with

description of site and extent.

c. Presence or absence of ill-defined diaphragmatic or cardiac outlines

with description of extent.

d. Any other pertinent findings of a chronic or acute nature.

X-rays should be kept available for review but should not be sent to this Office

unless requested. Additional views may be obtained at the discretion of the

physician.

In lieu of x-rays, the physician may elect to perform computerized axial tomography

(CAT scan) of the thorax, which can provide a more definitive view of the lungs and

the presence or absence of asbestosis.

5. Pulmonary Function Studies. To include measurement of the following

functions (the report of the results of the FVC, FEV(1), and diffusing capacity must

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include actual recorded values, the percent of predicted normal, and identification of

the normal standard applied for tests conducted before and/or after the use of

bronchodilators). These studies should be performed under the supervision or

direction of a Board-certified pulmonary specialist.

a. Forced Vital Capacity (FVC) and Forced Expiratory Volume in One

Second (FEV(1)) measured in liters and representing the best of three efforts

and the FEV(1)/FVC Ratio (FEV(1)%) computed from these results. Also

include total lung capacity (TLC). Report of the results of these tests must

include:

(1) Date and time of the test.

(2) Name, file number, sex, age, weight, and height of the patient.

(3) The names of the technician performing and the physician

supervising the test, if different from the referring physician.

(4) A description of the patient's ability to understand and follow

instructions and the degree of cooperation in performing the test.

(5) The paper speed (if applicable) and the name of the

instrument used.

(6) The date of last calibration of the instrument.

(7) Whether and why a bronchodilator was used and its impact on

test results.

The report must be accompanied by appropriately labeled spirometric

tracings (for all tests) showing distance per second on the abscissa

and distance per liter on the ordinate.

b. Carbon Monoxide Diffusing Capacity (Single Breath Method). The

results must be reported in ml/mm/mmHg. The report of the test must

include estimated alveolar volume (based on measured FRC), the barometric

pressure at the time of the test, the name of the technician performing the

test and the instrument used, and the date of last calibration.

c. Arterial Blood Gas Study, administered at rest. A blood gas study may

be done during exercise only if not medically contraindicated and if, in the

opinion of the examining physician, it is necessary for diagnostic purposes.

Report of the ABG study must include recorded values for pCO(2), pO(2), and

pH collected simultaneously; the date and time of the test; the altitude and

barometric pressure at which the test was conducted; the name of the

technician and supervising physician; the pulse rate at the time the blood

sample was drawn; the time elapsed between drawing and analysis of the

sample and whether the specimen was iced; the duration and time of exercise

(if appropriate); and a statement indicating that the equipment was calibrated

before and after each test.

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6. Electrocardiogram results submitted with tracings.

7. Complete Blood Count.

8. Medical Impression and Opinion which includes:

a. Diagnosis of all pulmonary conditions present.

b. Diagnosis of any other relevant disease condition present.

c. Recommendations regarding indicated course of treatment to improve

the level of pulmonary function.

d. A discussion of the findings regarding the indicated degree of

pulmonary impairment and exertional limitations (with reference to the

enclosed job description).

e. Discussion of work-relatedness, including a detailed discussion of other

possible etiological factors for each of the diagnosed conditions.

3-0600 Exhibit 8: Roentgenographic Interpretation

Page 1 (Link to Image)

Page 2 (Link to Image)

3-0600 Exhibit 9: Carpal Tunnel Cross-Sectional View (Link to Image)

CHAPTER 3-0700 - SCHEDULE AWARDS

TABLE OF CONTENTS

Paragraph and Subject Date Trans. No.

Table of Contents 01/10 10-04

1. Purpose 01/10 10-04

2. Definition and Standards for Evaluation 01/10 10-04

3. Determining Schedule Awards 01/10 10-04

4. Special Determinations 01/10 10-04

5. Disfigurement 01/10 10-04

* (ENTIRE CHAPTER REISSUED 01/10, TRANSMITTAL NO. 10-04)

Exhibits

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100

1. Use of the Sixth Edition of AMA Guides to The

Evaluation of Permanent Impairment 01/10 10-04

2. Percentage Table of Schedule Awards, Form CA-699 01/10 10-04

3. Hearing Loss Medical Opinion, Form CA-51 01/10 10-04

4. "Rating Spinal Nerve Extremity Impairment Using

the Sixth Edition" from July/August 2009 edition of The

Guides Newsletter, Published by the AMA 01/10 10-04

3-0700-1 Purpose

1. Purpose. The FECA provides that compensation may be paid for total or

partial loss, or loss of use of, certain parts of the body which are specified in the

FECA itself and in the regulations. The purpose of this chapter is to describe the

procedures involved in medical evaluation of claims for such awards.

3-0700-2 Definition and Standards for Evaluation

2. Definition and Standards for Evaluation. The phrase "permanent disability" in

5 U.S.C. 8107(a) is interpreted to mean "permanent physical impairment." The same

standards for evaluating such impairment are applied in all cases. The AMA Guides to

the Evaluation of Permanent Impairment is used in order to provide a consistent

method of calculating impairment. Exhibit 1 addresses calculations according to the

Sixth Edition of the Guides.

Since the Sixth Edition of the Guides is diagnosis based, the main factor in

determining impairment is the diagnosis itself. Each diagnosis grid is divided into five

classes of impairment severity, ranked from ‘0’ (no impairment) to ‘4’ (very severe).

Raters distinguish the level of severity using criteria separated into key factors and

non-key factors. These criteria consist of: (1) history of clinical presentation; (2)

physical findings; (3) clinical studies or objective test results; and (4) functional

history. All of these various factors affect the total amount of impairment awarded to

an individual.

3-0700-3 Determining Schedule Awards

3. Determining Schedule Awards. Development of cases for schedule awards is

discussed in PM Chapter 2-808. The Claims Examiner (CE) will ask the District

Medical Advisor (DMA) to evaluate a case when it appears to be in posture for

schedule award determination. The DMA is responsible for reviewing the file,

particularly the medical report on which the award is to be based, and then

calculating the award. A table showing the number of weeks of compensation

payable for various percentages of loss is shown as Exhibit 2.

a. Evaluating the Medical Report. The DMA should review the report of

the physician estimating impairment with respect to the following factors:

(1) Maximum Medical Improvement. Before an award may be

made, it must be medically determined that no further improvement

can be anticipated and the impairment must reach a fixed and

permanent state, which is known as Maximum Medical Improvement

(MMI).

(a) While additional medical treatment (such as surgery)

may be recommended in order to improve the claimant's

condition, the claimant is not required to undergo such

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101

treatment. See Santo Panzica, 13 ECAB 458 (1964). The Office

must calculate the percentage of the award as if no further

improvement were possible if the claimant declines such

intervention.

(b) It is well settled that maximum medical improvement

arises at the point at which an injury has stabilized and will not

improve further. This determination is factual in nature and

depends primarily on the medical evidence. See Peter C.

Belkind, 56 ECAB 580 (2005). Neither temporary nor future

impairment may be rated. Impairment should not be rated

permanent until sufficient time has passed for healing and

recovery, which may vary substantially depending on the

condition and the claimant. Clinical findings must indicate the

medical condition has stabilized. See Franklin Armfield, 28

ECAB 445 (1977). A schedule award may be payable based on

contemporaneous medical evidence of record showing a peak or

plateau in the claimant’s recovery status, even if the claimant's

condition is likely to deteriorate. Payment of an increased

award based on additional impairment may be considered at a

later date.

in the medical evidence requiring resolution under 5 U.S.C.

8123, the date of MMI is usually considered to be the date of

the attending physician’s evaluation that is accepted as

definitive by the Office.

(2) Description of Impairment. The attending physician should

describe the impairment in sufficient detail to permit clear visualization

of the impairment and the restrictions and limitations which have

resulted. The description should include the loss in degrees of active

and passive motion of the affected member or function, the amount of

any atrophy or deformity, disturbance of sensation, or other pertinent

description of the impairment. Under the Sixth Edition of the AMA

Guides, clinical history is also important in the diagnosis-based grid

that ranks impairment within classes of severity.

(3) Percentage of Impairment. Impairment evaluation results are

provided in terms of percentage of loss of use to the affected member

or function of the body (not the body as a whole, except where

impairment to the lungs and other bodily organs is at issue; see

paragraph 4 below). The percentage should include those conditions

accepted by OWCP as job-related and any pre-existing permanent

impairment of the same member or function. If the work-related injury

has affected any residual usefulness in whole or in part, a schedule

award may be appropriate. There are no provisions for apportionment

under the Act. Rated impairment should reflect the total loss as

evaluated for the schedule member at the time of the rating exam.

See Raymond E. Gwynn, 35 ECAB 247, 253 (1983) [In determining

the amount of a schedule award for a member of the body, pre-

existing impairments are to be included, citing Larson for the

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102

proposition that “the employer takes the employee as he finds him.”]

b. Calculation. The DMA should use the method of calculation set forth in

the AMA Guides. If it is necessary to deviate from the AMA Guides in

calculating an award, the record should reflect the basis for the deviation,

particularly when the use of a different table or evaluation materially affects

the percentage of the award. The policy of the Office is to round the

calculated percentage of impairment to the nearest whole point. Results

should be rounded down for figures less than .5 and up for .5 and over.

3-0700-4 Special Determinations

4. Special Determinations. Following are guidelines under §8107 of the Act for

calculating schedule awards for specific conditions:

a. Loss of Digits. While the percentage of impairment to the fingers is

generally computed in accordance with the AMA Guides, special computations

may be

required. In general, loss of more than one digit should be computed in

terms of

impairment to the whole hand or foot. The impairment computed for loss of

two or more digits occasionally exceeds the percentage for the hand or foot,

however, and in such instances the award should reflect the computation

most favorable to the claimant.

(1) Loss of Less Than One Phalanx. If less than one-half of a

phalanx has been amputated but some loss of bone or bony tuft has

occurred, the award shall be one-half of the amount payable for the

loss of the first phalanx or for 25 percent of the digit. If more than

half of a phalanx is lost, the award shall be for the entire loss of the

first phalanx, or for 50 percent of the digit.

Where significant amputation of the soft tissue of the tip of the first

phalanx has occurred with no loss of bone or bony tuft, the award shall

be one-fourth the amount payable for the loss of the first phalanx or

13 percent of the digit.

If the injury has caused impairment such as loss of flexion or

extension, swelling, gross deformity and/or changes in sensation in

addition to the amputation, the additional impairment must be

considered in the overall determination.

(2) Loss of Two or More Digits of a Hand or Foot. When there is a

loss of two or more digits, or one or more phalanges of each of two or

more digits, the award is proportional to the loss of use of the hand or

foot.

By statute, the loss of one phalanx will be considered equal to 50

percent of the digit and loss of more than one phalanx will be

considered equal to 100 percent of the digit. See 5 U.S.C. 8107 (15).

The value of each digit lost will then be applied to the hand or foot in

accordance with the AMA Guides. If the injury has caused impairment

such as nerve or palm involvement in addition to the amputation, such

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103

impairment must be considered in the determination. The DMA will

calculate the impairment of each digit separately and combine them

for a total percentage of loss to the hand or foot. Where the

cumulative allowances for the individual digits are greater than the

percentage of loss for the entire hand or foot, the higher percentage

should be used.

b. Loss of Hearing. After a complete report is received, the percentage of

hearing loss is calculated using Form CA-51 (Exhibit 3). The DMA will then

verify the calculation and the CE will certify the correctness of the DMA’s

computations. Adjudications based on just one audiogram should be avoided.

(1) Air vs. Bone Conduction. Air conduction studies provide a

complete picture of how well an individual can actually hear, while

bone conduction studies show what part of the hearing loss resulted

from nerve damage. While it is not unusual for air conduction studies

to show a greater hearing loss than bone conduction, the opposite

results are medically inconsistent and render the audiogram useless.

Therefore, while all audiograms must show test results for bone

conduction and pure tone air conduction studies, a schedule award

may not be based on the results of bone conduction studies.

(2) Computation. Effective February 24, 1986, hearing loss awards

are based on the formula contained in the AMA Guides. (FECA

Program Memoranda Nos. 162, 181, and 217 describe the previous

frequencies and computation methods.) Awards are computed as

follows:

(a) Monaural Loss. The average of decibel loss in the

frequencies of 500, 1000, 2000 and 3000 cps should first be

determined. From this amount 15 decibels should be

subtracted if ASA calibration was used and 25 decibels if ISO-

ANSI calibration was used. The result should be multiplied by a

factor of 1.5 to determine the percentage of loss.

(b) Binaural Loss. The monaural loss for each ear should

first be computed as described above. The percentage of loss

in the better ear should then be multiplied by five and the

result added to the percentage of loss in the worse ear. This

sum should then be divided by six to determine the percentage

of binaural loss. Percentages should not be rounded until the

final percent for award purposes is obtained. Fractions should

be rounded down from .49 or up from .50.

Between March 7, 1977 and February 23, 1986, the OWCP used only

the frequencies of 1000, 2000, and 3000 cps to determine an award

for hearing loss.

(3) Progression. Noise-induced hearing loss does not typically

progress after exposure to noise ceases. A claim with an audiogram

showing less than a 25 decibel loss soon after exposure ceases and a

second audiogram showing a ratable loss may be denied if the DMA

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104

provides a well-reasoned opinion. Other benefits are still payable if

any employment related hearing loss exists.

c. Loss of Vision. The percentage of impairment continues to be based on

best uncorrected vision. See 5 U.S.C. 8107 (19). Loss of binocular vision or

for loss of 80 percent or more is the same as for loss of the eye. See 5

U.S.C. 8107 (14).

d. Loss of Function of Bodily Organs. The FECA provides for award of

compensation due to permanent impairment to the extremities and organs.

However, most impairment ratings under the Sixth Edition of the AMA Guides

evaluate impairment based on injury or disease. Therefore, special

calculations are required to interpret certain ratings completed using the AMA

Guides into figures usable under the Act.

(1) Lung Impairment. All claims involving impairment of the lungs

where exposure occurred during Federal employment on or after

September 7, 1974 (see Program Memorandum No. 269) will be

evaluated for schedule

award purposes. The class of respiratory impairment should first be

established, following the AMA Guides as far as possible.

(a) While pulmonary function varies from day to day and

from environment to environment, impairment exists for

compensation purposes when the pulmonary function testing

reveals Class 1 or greater impairment severity as defined by

the AMA Guides.

(b) A Class 0 respiratory impairment equates to zero

percent impairment of the whole person. An individual in this

category would be considered to have no ratable loss and would

not be entitled to compensation under the Act.

the percentage for the particular class of whole person

respiratory impairment will be multiplied by 312 weeks (twice

the award for loss of function of one lung) to obtain the number

of weeks payable.

(d) In cases of anatomical loss by traumatic injury or

surgery, evaluation will also be based on loss of lung tissue (by

weight or volume). If the percentage of loss using this method

is higher than the percentage based on loss of respiratory

function, the award shall be made on the basis of loss of lung

tissue. Anatomical evaluations will be made only with regard to

the injured lung and will be based on a 156-week maximum

award for each lung. Anatomical loss awards can be made for

both lungs if the injury caused loss in both, but each lung must

be evaluated separately.

(2) Loss of Function of Other Organs. While the AMA Guides

express the impairment of bodily organs in terms of the whole person

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105

due to a particular injury or medical condition, a schedule award under

the FECA is based on the percentage of impairment of the particular

organ.

(a) Whole person impairment measurements can be directly

translated into organ ratings in the case of vital organs, such as

the lungs, where the total impairment of the organ(s) produces

100% impairment of the whole person. When the maximum

whole person rating of the organ is less than 100%, direct

translation of the whole person measurement into a percentage

of impairment to the organ is not valid. In these cases, to

obtain the percentage of impairment to an organ corresponding

to a given whole person impairment, the following

mathematical ratio should be used:

(A) = (X)

(B) 100

In this equation:

(A) = Actual whole person impairment of the claimant,

(B) = Maximum whole person impairment for the injury or

condition of the organ, and

(X) = Organ rating to be determined.

For example, if the maximum whole person impairment for an

injury or disease of an organ is 25% and the actual whole

person impairment of the claimant is 10%, then:

10 = (X)

25 100

(X) = 1000

(X) = 40% impairment of the organ

(b) For certain schedule organs which have more than one

physiologic function, the AMA Guides provide whole person

impairment scores for each affected system within that organ.

When calculating the impairment of these organs, the DMA

must consider all affected organ systems as instructed in the

AMA Guides.

In these cases, the maximum whole person impairment

ascribed to the particular organ injury or condition (B) is

obtained by combining the maximum levels for all functions

using the Combined Values Chart in the current edition of the

AMA Guides. The actual whole person impairment (A) is

obtained by combining all functional impairments found using

the Combined Values Chart in the Guides.

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106

For example, a claimant with an injury to the penis has a Class

3 penile (sexual) whole person impairment amounting to 15%,

and Class 2 urethral impairment of 10%. A 15% whole person

impairment combined with a 10% whole person impairment

results in a whole person impairment of 24%. The maximum

whole person impairment for the sexual function is 15% and

urethral function is 28%. Using the Combined Values Chart,

this amounts to 39% total whole person impairment. Then:

24 = X

39 100

X = 2400

X = 62% impairment of the penis

for loss of an organ. If there is total loss of a single

paired organ (such as a kidney, breast, testicle or

ovary), the schedule award is generally based on the

loss of the organ. In this situation, it is immaterial

whether the remaining organ compensates functionally

for the loss.

3-0700-5 Disfigurement

5. Disfigurement. The FECA [§8107(c)(21)] provides for payment of

compensation not to exceed $3500 for disfigurement of the face, head or neck which

is likely to handicap the claimant in securing or maintaining employment. The DMA

will be asked to review such claims and to evaluate the employee’s disfigurement. If

the DMA finds that maximum medical improvement has occurred, the DMA will

review the photographs submitted along with the medical evidence of record. The

concurrence of the Assistant District Director (ADD) or the District Director (DD)

must be obtained. Following the file review, the DMA and ADD or DD will write a

memorandum to the file which contains a complete description of the disfigurement.

If the DMA does not find that maximum medical improvement has occurred, but has

submitted a statement as to whether plastic surgery may improve the appearance

and decrease the degree of disfigurement and the claimant is amenable, the DMA

should include in his or her statement information concerning arrangements for

treatment.

3-0700 Exhibit 1: USE OF SIXTH EDITION OF AMA GUIDES

Effective May 1, 2009, OWCP began using the Sixth Edition of the AMA Guides. This

edition is significantly different from previous editions. There are extensive changes

affecting the calculations of schedule awards for FECA claimants.

The biggest adjustment from previous editions involves the rating of permanent

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107

impairment based on a specific diagnosis rather than the extremity or organ system.

In previous editions an impairment rating may have included multiple diagnoses

within an organ or extremity. Under the Sixth Edition most ratings will consider only

the diagnosis with the most impact on the rated bodily region. In the Fifth Edition of

the Guides impairment ratings relied heavily on loss of range of motion and strength

in comparison to a paired extremity. The Sixth Edition only incorporates these

findings as they relate to the specific diagnosis evaluated.

1. The Sixth Edition of the Guides implements a paradigm shift in the way

impairment evaluations are conducted. The stated vision of the Sixth Edition is

based on five axioms, including: (1) Adoption of terminology and conceptual

framework of disablement outlined by the World Health Organization’s (WHO’s)

International Classification of Functioning, Disability, and Health (ICF); (2) Becoming

more diagnosis-based and basing the diagnoses in evidence; (3) Optimizing rater

reliability through simplicity, ease of application, and following precedent; (4) Rating

percentages are functionally based to the fullest extent possible; and (5) Stressing

conceptual methodological congruity within and between organ rating systems.

2. The evaluation methodology used in the Sixth Edition substantially revises the

methods used in previous editions. The Guides characterize the objective of the new

methodology to be consistent, enhance relevancy, promote precision, and

standardize the rating process. The foundation of the new methodology is the

diagnosis-based grid used for each organ

system and chapter. Evaluators will rate impairment according to the diagnosis

representing the source of the most impairment in the given bodily region. If there

is more than one ratable diagnosis in an affected extremity, the rater should

combine all regional impairments for a final impairment at the extremity level.

Each diagnosis grid is divided into five classes of impairment severity, ranked from

‘0’ (no impairment) to ‘4’ (very severe). Within each class are five severity grades

categorized ‘A’ through ‘E’ (default ‘C’) with corresponding impairment percentages.

Raters distinguish the level of severity using criteria separated into key factors and

non-key factors. These criteria consist of: history of clinical presentation, physical

examination or physical findings, clinical studies or objective test results, and

functional history. In most organ systems or disease processes, clinical history is the

key factor which will determine the impairment class. However, objective test

results or physical findings may serve as the key factor in select organ system

evaluations. The evaluator will adjust the severity grade

based on the results of the remaining criteria. These adjustments cannot exceed

the percentage of impairment within the range specified by the designated class.

3. The Sixth Edition of the AMA Guides consists of seventeen chapters, one less than

the Fifth Edition. Two cardiovascular chapters in the Fifth Edition are consolidated

into one chapter in the Sixth.

4. Musculoskeletal regions in the Sixth Edition of the Guides consist of the upper

extremities (Chapter 15), lower extremities (Chapter 16), and the spine and pelvis

(Chapter 17). The upper extremity is divided into four separate regions, including

digits and hand, wrist, elbow, and shoulder. The lower extremity is divided into

three regions consisting of foot and ankle, knee, and hip. The spine and pelvis is

divided into four regions, including cervical, thoracic, and lumbar regions, and the

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108

pelvis, consisting of the ilium, ischium, pubis, sacrum and coccyx. Diagnosis classes

for the upper and lower extremities are broken into the following categories: Soft

tissue; muscle and tendon; ligament; and bone and joint. If impairment scores are

calculated in whole person ratings, they should be adjusted to individual extremity or

organ system percentages using conversion charts or rates.

5. Impairment to the upper or lower extremities that is caused by a spinal injury

should be rated consistent with the article “Rating Spinal Nerve Extremity

Impairment Using the Sixth Edition” in the July/August 2009 edition of The Guides

Newsletter published by AMA. The Guides Newsletter article (July/August publication

by the AMA) titled “Rating Spinal Nerve Extremity Impairment Using the Sixth

Edition” is Exhibit 4 in this chapter, and has been reproduced with permission from

the AMA.

6. The chapter on impairments due to pain (Chapter 3) has been updated. As with

the Fifth Edition, the Sixth Edition allows for a maximum 3% impairment rating for

non-specific pain that cannot be attributed to a condition addressed elsewhere in the

Guides. According to Section 3.3b:

Patients’ responses on functional assessment instruments will act as modifiers

of the percentage impairment they are awarded, the awards will, in general,

primarily reflect objective factors. This is in keeping with the general strategy

of the Guides to consider PRI [Pain-related impairment] but to limit the

amount of impairment that is awarded for subjective factors. In no

circumstances should the PRIs developed using this chapter be considered as

an add-on to impairment determinations based on the criteria listed in

Chapters 4 to 17. In essence, the PRIs derived according to this chapter are

determined in a stand-alone fashion.

7. Entrapment neuropathy of the upper extremities (e.g. carpal tunnel, cubital

tunnel, etc.) (Section 15.4f) must be documented with nerve conduction velocity

(NCV) testing in order to consider ratable impairment. If testing was not conducted

or does not meet the criteria outlined by the Guides, no ratable impairment may be

considered. Only pre-operative testing is used for rating impairment in this section.

Optimal rating time following surgical intervention is between nine months and 2

years. When evaluating multiple simultaneous neuropathies, the first (or most

impairing) is rated at 100%, the second is rated at 50%, and the third is rated at

0%. If there are more than three neuropathies, the neurology chapter should be

used rather than Chapter 15.

8. The Guides stipulate only permanent impairment may be rated, and only after

the claimant has reached a point of “maximum medical improvement” (MMI). The

Guides do not afford the rating of future impairment. Impairment should not be

rated permanent until sufficient time has passed for healing and recovery, which

may vary substantially depending on the condition and the claimant’s profile. The

clinical findings must indicate that the medical condition is stabilized for the claimant

to have reached MMI. The Guides define MMI as “a status where patients are as

good as they are going to be from the medical and surgical treatment available to

them.”

In cases where a claimant declines surgery or other curative treatment, an MMI

determination may still be reached. The evaluating physician should make a written

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109

note in the report discussing the appropriateness of the prescribed treatment and the

basis of the claimant’s declination. The physician should also indicate that the

individual is at MMI in lieu of additional treatment.

Claimants not at MMI, but with potential for future progression of their disease, can

be rated for permanent impairment on the current findings; MMI does not preclude

the worsening of a condition that is expected with the passage of time or due to the

aging process.

Exhibit 2: Percentage Table of Schedule Awards, Form CA-699

PERCENTAGE TABLE OF SCHEDULE AWARDS

(W = weeks; D = days)

MEMBER 01% 02%

03%

04%

05%

10% 15% 20%

Arm W 3.12 6.24

9.36

12.48

15.60

31.20 46.80 62.40

D 21.84 43.68

65.52

87.36

109.20

218.40 327.60 436.80

Leg W 2.88 5.76

8.64

11.52

14.40

28.80 43.20 57.60

D 20.16 40.32

60.48

80.64

100.80

201.60 302.40 403.20

Hand W 2.44 4.88

7.32

9.76

12.20

24.40 36.60 48.80

D 17.08 34.16

51.24

68.32

85.40

170.80 256.20 341.60

Foot/Penis W 2.05 4.10

6.15

8.20

10.25

20.50 30.75 41.00

D 14.35 28.70

43.05

57.40

71.75

143.50 215.25 287.00

Vulva/Vagina

Uterus/Cervix W 2.05 4.10

6.15

8.20

10.25

20.50 30.75 41.00

D 14.35 28.70

43.05

57.40

71.75

143.50 215.25 287.00

Larynx/

Tongue W 1.60 3.20

4.80

6.40

8.00

16.00 24.00 32.00

D 11.20 22.40

33.60

44.80

56.00

112.00 168.00 224.00

Eye W 1.60 3.20

4.80

6.40

8.00

16.00 24.00 32.00

D 11.20 22.40

33.60

44.80

56.00

112.00 168.00 224.00

Kidney/

Lung W 1.56 3.12

4.68

6.24

7.80

15.60 23.40 31.20

D 10.92 21.84

32.76

43.68

54.60

109.20 163.80 218.40

Thumb W .75 1.50

2.25

3.00

3.75

7.50 11.25 15.00

D 5.25 10.50

15.75

21.00

26.25

52.50 78.75 105.00

1st Finger W .46 .92

1.38

1.84

2.30

4.60 6.90 9.20

D 3.22 6.44

9.66

12.88

16.10

32.20 48.30 64.40

Great Toe W .38 .76

1.14

1.52

1.90

3.80 5.70 7.60

D 2.66 5.32

7.98

10.64

13.30

26.60 39.90 53.20

2nd Finger W .30 .60

.90

1.20

1.50

3.00 4.50 6.00

D 2.10 4.20

6.30

8.40

10.50

21.00 31.50 42.00

3rd Finger W .25 .50

.75

1.00

1.25

2.50 3.75 5.00

D 1.75 3.50

5.25

7.00

8.75

17.50 26.25 35.00

Toe other

Great Toe W .16 .32

.48

.64

.80

1.60 2.40 3.20

D 1.12 2.24

3.36

4.48

5.60

11.20 16.80 22.40

4th Finger W .15 .30

.45

.60

.75

1.50 2.25 3.00

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110

D 1.05 2.10

3.15

4.20

5.25

10.50 15.75 21.00

Hearing

(1 ear) W .52 1.04

1.56

2.08

2.60

5.20 7.80 10.40

D 3.64 7.28

10.92

14.56

18.20

36.40 54.60 72.80

Testicle/

Breast/Ovary* W 52 1.04

1.56

2.08

2.60

5.20 7.80 10.40

D 3.64 7.28

10.92

14.56

18.20

36.40 54.60 72.80

Hearing

(Both ears) W 2.00 4.00

6.00

8.00

10.00

20.00 30.00 40.00

D 14.00 28.00

42.00

56.00

70.00

140.00 210.00 280.00

* Includes Fallopian tube

(W = weeks; D = days)

MEMBER 25% 30%

35%

40%

45%

50% 55%

60%

Arm W 78.00 93.60

109.20

124.80

140.40

156.00 171.60

187.20

D 546.00 655.20

764.40

873.60

982.80

1092.00 1201.20

1310.40

Leg W 72.00 86.40

100.80

115.20

129.60

144.00 158.40

172.80

D 504.00 604.80

705.60

806.40

907.20

1008.00 1108.80

1209.60

Hand W 61.00 73.20

85.40

97.60

109.80

122.00 134.20

146.40

D 427.00 512.40

597.80

683.20

768.60

854.00 939.40

1024.80

Foot/ Penis/ W 51.25 61.50

71.75

82.00

92.25

102.50 112.75

123.00

D 358.75 430.50

502.25

574.00

645.75

717.50 789.25

861.00

Vulva/Vagina

Uterus/Cervix W 51.25 61.50

71.75

82.00

92.25

102.50 112.75

123.00

D 358.75 430.50

502.25

574.00

645.75

717.50 789.25

861.00

Larynx/

Tongue W 40.00 48.00

56.00

64.00

72.00

80.00 88.00

96.00

D 280.00 336.00

392.00

448.00

504.00

560.00 616.00

672.00

Eye W 40.00 48.00

56.00

64.00

72.00

80.00 88.00

96.00

D 280.00 336.00

392.00

448.00

504.00

560.00 616.00

672.00

Kidney/ Lung W 39.00 46.80

54.60

62.40

70.20

78.00 85.80

93.60

D 273.00 327.60

382.20

36.80

491.40

546.00 600.60

655.20

Thumb W 18.75 22.50

26.25

30.00

33.75

37.50 41.25

45.00

D 131.25 157.50

183.75

210.00

236.25

262.50 288.75

315.00

1st Finger W 11.50 13.80

16.10

18.40

20.70

23.00 25.30

27.60

D 80.50 96.60

112.70

128.80

144.90

161.00 177.10

193.20

Great Toe W 9.50 11.40

13.30

15.20

17.10

19.00 20.90

22.80

D 66.50 79.80

93.101

106.40

119.70

133.00 146.30

159.60

2nd Finger W 7.50 9.00

10.50

12.00

13.50

15.00 16.50

18.00

D 52.50 63.00

73.50

84.00

94.50

105.00 115.50

26.00

3rd Finger W 6.25 7.50

8.75

10.00

11.25

12.50 13.75

15.00

D 43.75 52.50

61.25

70.00

78.75

87.50 96.25

105.00

Toe (No

Great Toe) W 4.00 4.8

5.60

6.40

7.20

8.00 8.80

9.60

D 28.00 33.60

39.20

44.80

50.40

56.00 61.60

67.20

4th Finger W 3.75 4.50

5.25

6.00

6.75

7.50 8.25

9.00

D 26.25 31.50

36.75

42.00

47.25

52.50 57.75

63.00

Hearing

(1 ear) W 13.00 15.60

18.20

20.80

23.40

26.00 28.60

31.20

D 91.00 109.20

127.40

145.60

163.80

182.00 200.20

18.40

FECA-PT3 Printed: 08/02/2011

111

Testicle/

Breast/Ovary* W 13.00 15.60

18.20

20.80

23.40

26.00 28.60

31.20

D 91.00 109.20

127.40

145.60

163.80

182.00 200.20

218.40

Hearing

(Both ears) W 50.00 60.00

70.00

80.00

90.00

100.00 110.00

120.00

D 350.00 420.00

490.00

560.00

630.00

700.00 770.00

840.00

* Includes Fallopian tube

(W = weeks; D = days)

MEMBER 65% 70%

75%

80%

85% 90% 95%

100%

Arm W 202.80 218.40

234.00

249.60

265.20 280.80 296.40

312.00

D 1419.60 1528.80

1638.00

1747.20

1856.40 1965.60 2074.80

2184.00

Leg W 187.20 201.60

216.00

230.40

244.80 259.20 273.60

288.00

D 1310.40 1411.20

1512.00

1612.80

1713.60 1814.40 1915.20

2016.00

Hand W 158.60 170.80

183.00

195.20

207.40 219.60 231.80

244.00

D 1110.20 1195.60

1281.00

1366.40

1451.80 1537.20 1622.60

1708.00

Foot/

Penis/ W 133.25 143.50

153.75

164.00

174.25 184.50 194.75

205.00

D 932.75 1004.50

1076.25

1148.00

1219.75 1291.50 1363.25

1435.00

Vulva/Vagina

Uterus/Cervix W 133.25 143.50

153.75

164.00

174.25 184.50 194.75

205.00

D 932.75 1004.50

1076.25

1148.00

1219.75 1291.50 1363.25

1435.00

Larynx/

Tongue W 104.00 112.00

120.00

128.00

136.00 144.00 152.00

160.00

D 728.00 784.00

840.00

896.00

952.00 1008.00 1064.00

1120.00

Eye W 104.00 112.00

120.00

160.00

160.00 160.00 160.00

160.00

D 728.00 784.00

840.00

1120.00

1120.00 1120.00 1120.00

1120.00

Kidney/

Lung W 101.40 109.20

117.00

124.80

132.60 140.40 148.20

156.00

D 709.80 764.40

819.00

873.60

928.20 982.80 1037.40

1092.00

Thumb W 48.75 52.50

56.25

60.00

63.75 67.50 71.25

75.00

D 341.25 367.50

393.75

420.00

446.25 472.50 498.75

525.00

1st Finger W 29.90 32.20

34.50

36.80

39.10 41.40 43.70

46.00

D 209.30 225.40

241.50

257.60

273.70 289.80 305.90

322.00

Great Toe W 24.70 26.60

28.50

30.40

32.30 34.20 36.10

38.00

D 172.90 186.20

199.50

212.80

226.10 239.40 252.70

266.00

2nd Finger W 19.50 21.00

22.50

24.00

25.50 27.00 28.50

30.00

D 136.50 147.00

157.50

168.00

178.50 189.00 199.50

210.00

3rd Finger W 16.25 17.50

18.75

20.00

21.25 22.50 23.75

25.00

D 113.75 122.50

131.25

140.00

148.75 157.50 166.25

175.00

Toe (Not

Great Toe) W 10.40 11.20

12.00

12.80

13.60 14.40 15.20

16.00

D 72.80 78.40

84.00

89.60

95.20 100.80 106.40

112.00

4th Finger W 9.75 10.50

11.25

12.00

12.75 13.50 14.25

15.00

D 68.25 73.50

78.75

84.00

89.25 94.50 99.75

105.00

Hearing

(1 ear) W 33.80 36.40

39.00

41.60

44.20 46.80 49.40

52.00

D 236.60 254.80

273.00

291.00

309.40 327.60 345.80

364.00

Testicle/

Breast/Ovary* W 33.80 36.40

39.00

41.60

44.20 46.80 49.40

52.00

D 236.60 254.80

273.00

291.00

309.40 327.60 345.80

364.00

Hearing

(Both ears) W 130.00 140.00

150.00

160.00

170.00 180.00 190.00

200.00

D 910.00 980.00

1050.00

1120.00

1190.00 1260.00 1330.00

1400.00

FECA-PT3 Printed: 08/02/2011

112

* Includes Fallopian tube

3-0700 Exhibit 3: Hearing Loss Medical Opinion, Form CA-51 ( Link to Image)

HEARING LOSS MEDICAL OPINION, FORM CA-51

1. Date: 2. File Number:

3.. In response to memorandum dated:

Yes No

Sensorineural Hearing Loss: Binaural Monaural

4. Date of Maxiumum Improvement:

(same date as audiogram)

5. Date audiometer calibrated:

6. ASA ISO ANSI (Circle Appropriate reading)

7. Right Ear:

500 cps _______

1000 cps _______

2000 cps _______

3000 cps _______

Total: _______ ÷ 4 = __________

Less Fence: -25

Balance: __________ X 1.5 = __________ Monaural loss

8. Left Ear:

500 cps _______

1000 cps _______

2000 cps _______

3000 cps _______

Total: _______ ÷ 4 = __________

Less Fence: -25

Balance: __________ X 1.5 = __________ Monaural loss

9. 5 ( __ ) + ( __ ) =

6 __________% binaural loss

10. Hearing Aid Authorized? Yes No

11. Recommend Examination by Specialist? Yes No

12. District Medial Director

13. Date

13.

Claims Examiner

14. Date

15.

Certifier

16 Date

Form Ca-51

FECA-PT3 Printed: 08/02/2011

113

3-0700 Exhibit 4: Use of Sixth Edition of AMA Guides (PLEASE CLICK THE

IMAGE BELOW TO ACCESS THE FULL NEWSLETTER)

FECA-PT3 Printed: 08/02/2011

114

FECA-PT3 Printed: 08/02/2011

115

CHAPTER 3-0800 - EXCLUSION OF

MEDICAL PROVIDERS

TABLE OF CONTENTS

Paragraph Subject Date Trans. No.

Table of Contents 05/94 94-24

1. Purpose 10/90 91-02

2. Extent of Sanctions 10/90 91-02

3. Automatic Exclusion 10/90 91-02

4. Non-Automatic Exclusion 10/90 91-02

5. Formal Notification to Providers 10/90 91-02

6. Procedures for Exclusion 10/90 91-02

7. Documentation and Advice to Affected Claimants 10/90 91-02

Exhibits

1. Procedures for Excluding Medical

Providers (Link to Image) 12/94 95-04

2. Sample Letter of Intent to Exclude 12/94 95-04

3. Sample Decision to Exclude 12/94 95-04

3-0800-1 Purpose

1. Purpose. Regulations appearing at 20 C.F.R. 10.450-457 furnish the basis for

excluding medical providers, including physicians, hospitals, or suppliers of medical

support services or appliances, from participation and payment under the FECA for

fraud, abuse and other unacceptable practices. The regulations provide a

mechanism for initiating and effecting exclusion while ensuring due process for

medical providers. They also provide for reinstatement after specified time periods if

reasonable assurance exists that the action which led to the exclusion will not recur.

The purpose of this chapter is to describe the bases for exclusion and the procedures

for excluding and reinstating medical providers. The procedures are shown in

diagrammatic form in Exhibit 1 (Link to Image).

3-0800-2 Extent of Sanctions

2. Extent of Sanctions. Excluded providers are not authorized to render services

and OWCP will not pay their bills. Medical reports from an excluded physician may

not be disregarded, but they may be accorded diminished probative value if the

reason for exclusion warrants it. A memorandum should appear in the case file

showing the reason for exclusion and the rationale for according diminished

probative value to the report. The Claims Examiner (CE) should prepare the

memorandum unless the reasons for exclusion or the extent to which the probative

value is diminished require the expertise of the District Medical Adviser (DMA) to

prepare it.

FECA-PT3 Printed: 08/02/2011

116

3-0800-3 Automatic Exclusion

3. Automatic Exclusion. A provider is automatically excluded

from participation under the FECA if he or she has been:

a. Convicted under any criminal statute for fraudulent activities in

connection with any Federal or State program for which payments are made

to providers for similar medical, surgical, or hospital appliances or supplies; or

b. Excluded or suspended, or has resigned in lieu of exclusion or

suspension, from participation in such a program.

Most automatic exclusions will result from action by Medicare, which is

administered by the Health Care Financing Administration (HCFA), but some

will result from action by other Federal programs or by state Medicaid

programs. (The grounds for exclusion under HCFA include sale and

distribution of illegal drugs.) Providers convicted under any criminal statute

for fraudulent activities in connection with any Federal or state program for

which payments are made for medical services are also automatically

excluded by OWCP. District offices should notify the National Office of any

convicted providers who are not on the exclusion list. Since such convictions

are sometimes overturned on appeal, the district office should not exclude

providers under these procedures until documentation of the conviction is

obtained by the National Office.

3-0800-4 Non-Automatic Exclusion

4. Non-Automatic Exclusion. Exclusion for reasons other than those noted

above is not automatic and must be initiated in the district office. A provider is

subject to exclusion for fraud or abuse if she/he has:

a. Knowingly made or caused to be made any false statement or

misrepresentation of a material fact in connection with a determination of the

right to reimbursement under the FECA, or in connection with a request for

payment (20 C.F.R. 10.450(c)). This provision generally applies to billings for

services or supplies which were never furnished.

(1) Unusually Frequent Billings. DMAs, CEs and Benefit Payment

Clerks (BPCs) should be alert to instances of unusually frequent office

visits or use of prescription drugs or supplies. In such instances the

CE should write to the claimant and ask whether the services or

supplies in question were actually received and, if so, why the claimant

believes they were needed.

(2) Contacting Physicians. If the claimant states that some

services or supplies were never furnished and the provider is a

physician, the CE will refer the case to the DMA, who should write to

the physician, describe the apparent false billing, and request an

explanation within 30 days. The DMA should review any reply within

the context of the case and prepare a memorandum to the

Supervisory Claims Examiner (SCE) concerning possible violation of

the regulations. If the physician does not reply within 30 days, the

DMA should so advise the SCE.

FECA-PT3 Printed: 08/02/2011

117

(3) Contacting Non-Physicians. If the claimant states that some

services or supplies were never furnished and the provider is not a

physician, the CE will contact him or her to obtain an explanation. If

the provider does not reply, or if the reply fails to establish that the

billing in question was appropriate, the CE should prepare a

memorandum to the Assistant District Director as described in

paragraph 9 (a)(1) of PM Chapter 2-402 for possible referral to the

Office of the Inspector General.

b. Submitted, or caused to be submitted, three or more bills or requests

for payment under the FECA within a twelve-month period containing charges

which the Office finds are substantially in excess of the provider's customary

charges, unless it is found that there is good cause for the bills or requests

containing such charges (20 C.F.R. 450(d)).

(1) Reimbursement. A provider who charges more than the

amount allowed by the fee schedule will not be penalized if the amount

corresponds to the amount charged other patients. If the claimant has

paid the full amount charged prior to notification that the excess is not

payable, and then requests reimbursement, the provider will be asked

to reimburse the claimant for the amount over and above the

allowable fee or submit an explanation to OWCP for the additional

charge. Failure of the provider to make such reimbursement within a

reasonable time or to provide satisfactory justification will be deemed

collection of a fee warranting initiation of the exclusion procedures.

(2) Notification. If the provider is charging FECA claimants a

significantly higher price for identical services, appliances, or supplies,

the DMA should write to the provider. The letter should state that the

Office has found through investigation that it is being billed more

than the customary charge for the specific service(s) and invite the

provider to give the reason, if any, for the higher charges. The

provider should also be advised that absent such reasons he or she

should cease such practice or face possible exclusion.

(3) Response. If the provider replies that the extra charges are

made because of special requirements of FECA cases, such as

studying files or writing medical reports, he or she should be

instructed to show the charge for reports and file review separately.

(4) Advice to RD. Serious or persistent occurrences of excessive

billing should be reported to the District Director (DD), and the DMA or

DD should telephone the provider to discuss the problem. If the

provider fails to cooperate, documentation of the situation should be

routed to the Regional Director (RD) for further action. The

documentation should include detailed written accounts of all

telephone conversations as well as copies of pertinent correspondence.

c. Knowingly failed to timely reimburse claimants for treatment, services,

or supplies furnished under the FECA and paid by the Government (20 C.F.R.

10.450(e)).

(1) Dual Payment. If a claimant states that he or she paid for

FECA-PT3 Printed: 08/02/2011

118

services or supplies which were also paid by the Office without

subsequent reimbursement, the SCE should write a letter of warning

to the provider, with a copy to the claimant. The letter should bring

the dual payment to the provider's attention and ask him or her to

reimburse the claimant without delay. The letter should quote the

grounds for exclusion and state that initiation of exclusion proceedings

will be considered if the claimant is not reimbursed within 30 days.

(2) Follow-up. The SCE or CE should contact the claimant 30 days

after release of this letter to ensure that the claimant has received the

reimbursement. If not, a copy of all material related to the complaint

should be routed to the DD. Serious or persistent offenses should be

referred to the RD for consideration of exclusion, and material on such

providers should be maintained in the Provider Exclusion File.

d. Failed, neglected, or refused, on three or more occasions during a

twelve-month period, to submit full and accurate medical reports, or to

respond to requests by the Office for additional reports or information, as

required by the FECA and by 20 C.F.R. 10.450 (f)).

(1) No Response. When a third request for a medical report must

be made and a response is not received within a reasonable period,

the CE will refer the case to the DMA. The DMA will telephone the

provider and explain the problem, noting that failure to submit full and

accurate reports or to respond to a reasonable request for further

information may lead to exclusion from the program.

(2) Inadequate Response. The CE should also refer the case to

the DMA when a medical report is incomplete and/or inaccurate and

repeated requests for additional information have not received

satisfactory response. The DMA should state whether the information

is in fact incomplete or inaccurate, and if the request for additional

reports or information is reasonable. If so, the DMA should telephone

the provider as described above.

(3) Further Action. In intractable cases, the DMA should refer the

matter to the DD, who will study the documentation and take further

action as indicated, such as additional contact with the provider or

referral to the RD for consideration of exclusion.

e. Knowingly furnished treatment, services, or supplies which are

substantially in excess of the claimant's needs, or of a quality which fails to

meet professionally recognized standards (20 C.F.R. 10.450 (g)).

(1) DMA Advice. CEs and BPCs may ask the DMA if services or

supplies are substantially in excess of a claimant's needs or fail to

meet professionally recognized standards. The DMA should place a

memorandum in the file which addresses the issue and which contains

medical rationale for the opinion. The DMA may also identify instances

of excessive treatment, services, or supplies in the course of

reviewing cases for other reasons. Any question regarding standards

or quality should be referred to the DMA for advice and opinion.

FECA-PT3 Printed: 08/02/2011

119

(2) Contacting Physicians. The DMA will telephone a provider who

is a physician and discuss the issue. If the discussion does not resolve

the problem, the DMA will write a letter of warning to the provider

which specifies the services or supplies and gives the reason why they

are considered excessive or unacceptable and do not meet

professionally recognized standards. The letter will also quote the

exclusion provision of 20 C.F.R. 10.450 (g).

(3) Contacting Non-Physicians. The SCE will write a letter of

warning to a provider who is not a physician, citing the regulations

and explaining why the services or supplies are considered to be in

violation of them.

(4) Referral to RD. If the DMA finds that a provider is engaging in

a medical practice which is life- threatening or harmful, the DMA will

refer the matter to the DD with all documentation for routing to the

RD.

While non-automatic exclusion may be initiated for any of the practices indicated

above, the right to exclude a provider should be exercised with restraint. Every

effort should be made to correct unacceptable or deficient practices by letters and

telephone calls before taking further action. The RD will initiate exclusion only when

it becomes apparent that continued attempts to educate and persuade will not

terminate unacceptable activities. Of course, it is not necessary or desirable to

attempt to reform a provider who is engaging in harmful medical practices. In such

cases exclusion should be undertaken without delay.

3-0800-5 Formal Notification to Providers

5. Formal Notification to Providers. It is essential that the district office act

promptly after grounds for exclusion are discovered, since abuses must be curtailed

without delay. Cases referred to the SCE and to typing for warning letters should

receive priority queuing, and material forwarded to the RD for consideration of

exclusion should be designated as "special" and treated as such during all processing

in the RD's office.

a. Provider Exclusion File. The RD will maintain a Provider Exclusion File

containing copies of evidence, memoranda and letters to reflect action taken

by the district office in each instance of alleged fraud or abuse. When such

material is routed to the RD, he or she will review it along with any other

material in the file on the same provider.

b. Preliminary Steps. The RD will obtain whatever additional information

he or she may deem appropriate and will try to resolve the problem without

issuing a letter of intent to exclude. The RD will ensure that thorough and

reasonable steps were taken by district office staff to curtail unacceptable

provider practices. If feasible, the RD may suggest that a meeting be

arranged with the provider and the DMA present in order to achieve

compliance. If the provider is amenable to a conference call, it should be

arranged.

c. Consultation with Solicitor and National Office. If reasonable

FECA-PT3 Printed: 08/02/2011

120

educational and persuasive efforts have proven futile, or in the event of a

harmful or life-threatening medical practice, the RD should discuss the

situation with the Regional Office of the Solicitor. Prior to drafting a letter of

intent to exclude, the RD shall telephone the Director for FEC to apprise him

or her of the proposed action and the reasons for it. A sample letter of intent

meeting the requirements of 20 C.F.R. 10.452 is shown as Exhibit 2.

d. Letter of Intent. The RD may issue a letter of intent to exclude if the

provider has engaged in an unacceptable practice in violation of 20 C.F.R.

10.450 (c), (e) or (g). The RD may also issue a letter of intent to exclude for

violation of 20 C.F.R. 10.450 (d) or (f) if there have been three instances of

violation of either subsection (d) or (f) within any continuous twelve-month

period. The instances of excessive charges or deficient reports may have

occurred in the same or different cases.

(1) Excessive Charges. In order to be counted as an offense

toward violation of 20 C.F.R. 10.450 (d), the excessive charges must

be for services or supplies furnished on different dates, not duplicate

billings for the same goods or service. Each excessive billing for a

service or supply which is furnished on different occasions would

constitute a separate and distinct occurrence which should be counted

individually. For example, excessive charges for each of three office

visits within a continuous twelve-month period will be grounds for

exclusion.

(2) Inadequate Reports. Each instance of failure, neglect or refusal to

submit a full and accurate medical report in response to a specific

request by the district office, or to respond to a request for additional

information, will be considered as one offense toward violation of 20

C.F.R. 10.450 (f). An initial inadequate report which is not submitted

in response to a specific request from the Office will not count as an

offense.

(3) Cumulative Occurrences. The regulations specify three

instances of excessive charges or three instances of deficiencies in

reports as separate grounds for exclusion. Therefore, two instances of

one and one instance of the other will not constitute a basis for

exclusion.

e. Information to Provider. The letter to the provider must be sent by

certified mail, return receipt requested. Copies of supporting evidence such

as deficient medical reports and documentation of billing improprieties may

be attached as appropriate. The RD will maintain a five week call-up for the

provider's response. A copy of the letter of intent and appropriate

documentation should be sent to the Director for FEC.

3-0800-6 Procedures for Exclusion

6. Procedures for Exclusion. The RD will ensure that the provider has a full 30

days to reply to the letter of intent before taking further action.

a. Provider Response.

(1) No Response. If the provider fails to give written response

FECA-PT3 Printed: 08/02/2011

121

within 30 calendar days, the RD will issue a decision to exclude as

described below.

(2) Resignation. If the provider responds by submitting a letter of

resignation, the RD will so inform the Director for FEC by telephone

and follow up with a brief memorandum giving the provider's name,

address and Tax Identification Number (TIN). The reinstatement

provisions at 10.457(a) do not apply to those who resign. The RD

should therefore write to the provider simply to acknowledge receipt

of the resignation. If the provider resigns verbally, the RD should

send him or her a letter confirming the resignation for his or her

signature and allow 30 days for return of the signed resignation.

(3) Additional Evidence. If the provider responds

within 30 calendar days with a request for consideration of additional

evidence, the RD will carefully study all the evidence and decide

whether or not the provider should be excluded. The RD should

maintain liaison with the Solicitor's Office and should keep the

Associate Director informed by telephone of the contents of any reply

and its effect on the decision.

b. Issuing the Decision.

(1) Contents. The RD will send a letter decision stating the reasons

for exclusion to the provider by certified mail, return receipt

requested. If no reply was received to the letter of i251"n sßicision

stating5f icconponao ried o f"sitheply wft ofniciontit proed tsubmsto rn

stathetg5f evathao riirequlit proter of erolit pr twhichby cmpo ri of

i251"n sßicisiowill setating ththetgatso iccthtader by"g dn sßto the prn

athtoplinit pro sßs for ice reemsioby cthss atdder by certif'

toightsoterft ofnr erewo sßs foto the prwilA copyo sßs fotating

thehouldg5f ssiobter of Dio ttersion FECwilA samplfotating

thinhehowthithExhibsta3wi

(2) Request for Hearing. A decision to exclude takes effect 30

calendar days from the date of the decision. During this period, the

provider may file a request for a hearing before an Administrative Law

Judge (ALJ) by addressing such request to the RD. The filing of a

request for hearing within the 30 calendar day period stays the

decision to exclude. Therefore, flagging of the automated provider file

and notification of other parties must be held for 30 calendar days

pending a request for a hearing.

(3) Further Action. If no request for a hearing is received within 30

calendar days following the RD's letter of decision, the RD shall so

notify the Director for FEC in writing. The National Office will add the

provider's name to the list of excluded providers distributed to all

district offices and will notify state and local licensing agencies.

c. Requests for Hearing.

(1) Forwarding the Request. If a request for a hearing is received

FECA-PT3 Printed: 08/02/2011

122

within 30 calendar days, the RD will send it to the Office of

Administrative Law Judges, U.S. Department of Labor, 200

Constitution Avenue, N.W., Washington, D.C. 20210. A copy will be

retained in the Provider Exclusion File.

(2) Copies of Request. A copy of the request for hearing will be

sent to the Regional Solicitor, with a copy of all information concerning

the provider from the Provider Exclusion File. Another copy of the

request for hearing will be sent to the Director for FEC.

(3) Late Requests. If a request for a hearing is received later than

30 calendar days from the decision, the RD will advise the provider

that it was not timely filed and that the request cannot be honored. A

copy of this letter should be sent to the Director for FEC.

(4) ALJ Decision. The decision of the ALJ is effective on the date

issued. An ALJ decision affirming exclusion can be stayed only by

order of the Director, upon petition for review filed for grounds

specified at 20 C.F.R. 10.455(c). Review by the Director is a matter of

discretion rather than right. Upon notification of an ALJ's decision

affirming exclusion, the district office and National Office will effect

the exclusion by notifying interested parties and implementing stop

payment flags and related procedures as described below.

d. Reinstatement of an Excluded Provider. An excluded provider may be

reinstated after specified time periods, but only when reasonable assurances

exist that the basis for the exclusion will not be repeated. Reinstatement is

considered in the National Office and each district office will be advised of any

reinstated providers.

3-0800-7 Documentation and Advice to Affected Claimants

7. Documentation and Advice to Affected Claimants. The National Office

periodically publishes lists of excluded and reinstated providers which are organized

by state and distributed to district offices.

a. List of Excluded Providers. Upon receiving the list, the district office

should detach and reproduce the section of the list covering physicians within

its jurisdiction and distribute it to local Federal agencies. The district office

should also compare the list to its Provider Master File to identify any

excluded providers who are treating claimants. For any excluded provider

identified, the district office will run a Provider Utilization Report without

awaiting receipt of the next general list.

b. Notification to Claimant. Form CA-1342 should be sent to each

claimant seen by the provider within the past six months. The letter will

inform the claimant that the provider has been excluded from furnishing

medical services, supplies or appliances under the FECA and that any charges

incurred more than 15 days after the date of the letter will not be paid. If the

excluded provider is a physician, the claimant will be asked to select another

physician and advised that he or she will be responsible for all charges

incurred if treatment with the excluded physician is continued.

FECA-PT3 Printed: 08/02/2011

123

c. Removal from Roster. The Medical Management Assistant (MMA) will

delete the excluded provider, if a physician, from the roster of second opinion

and referee physicians. If an examination with the excluded physician is

pending, the MMA will cancel the appointment and arrange to have the

claimant examined by another specialist. If the excluded physician has been

following a claimant after referral by the Office, care should be transferred to

another physician.

d. Claimant Responses. If a claimant who is using the services of an

excluded provider asks that the provider continue to be authorized to render

services in his or her case and/or that the Office continue to pay for such

services, the CE should explain as tactfully as possible the reason the provider

has been excluded and why it is in the best interests of the claimant and the

Office to use another provider.

e. Formal Decisions. If the claimant persists in submitting bills from the

excluded provider, a compensation order should be issued rejecting the claim

for services, supplies or appliances furnished by the provider for the reason

that the provider has been excluded under 20 C.F.R. 10.450. As in any other

adverse decision, the denial should be accompanied by the rights to hearing,

reconsideration and appeal.

3-0800 Exhibit 1: Procedures for Excluding Medical Providers (Link to

Image)

3-0800 Exhibit 2: Sample Letter of Intent To Exclude

Dear NAME OF RECIPIENT:

I am writing to inform you that it is my intention to exclude [you, and/or name of

hospital, firm, etc.] from payment and participation as a provider of medical

services, medical support services, and/or supplies to injured Federal employees

under the Federal Employees' Compensation Act.

This action will be taken because [concisely state the grounds and cite the C.F.R.

section, e.g. "you submitted three bills in a twelve month period substantially

exceeding your customary charges for these services without good cause, a violation

of 20 C.F.R. 10.450(d)." Then summarize the information you relied upon and refer

to supporting documentation which will be attached].

Please telephone me at TELEPHONE NUMBER if you wish to inspect the record or

obtain copies of any documentation not attached.

If you do not contest this action, you may resign voluntarily from participation in the

FECA program without admitting or denying the above-stated grounds for exclusion.

If you do not choose to resign, you may request a decision on exclusion based upon

the existing record and any additional documentary information you may wish to

provide. You will have the right to request a formal hearing on any adverse decision

before an Administrative Law Judge.

Your answer must be received by the undersigned within 30 days. You must state

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whether (a) you are resigning voluntarily or (b) you are requesting a determination

on the existing record and any additional information you are providing. If you

chose option (b), the additional information, if any, must be enclosed with your

reply.

If you do not reply within 30 days of your receipt of this letter, it will be assumed

that the allegations contained above are true, and you will be excluded from the

FECA program as proposed.

Sincerely,

REGIONAL DIRECTOR

3-0800 Exhibit 3: Sample Decision To Exclude

Dear NAME OF RECIPIENT:

Inasmuch as you have not responded to my letter of DATE, wherein I proposed to

exclude you as a provider of [medical services, medical support services, supplies]

under the Federal Employees' Compensation Act, the allegations stated in that letter

are deemed to be true and are hereby incorporated as a part of this letter decision.

I have carefully reviewed the information you submitted in response to my letter

dated DATE, wherein I proposed to exclude you as a provider of (medical services,

medical support services, supplies) under the Federal Employees' Compensation Act.

[Include discussion of findings.]

Based upon these findings, NAME OF PROVIDER is hereby excluded from

participation and payment as a provider under the Federal Employees' Compensation

Act, for violation of 20 C.F.R. 10.450 [specify c, d, e, f and/or g, whichever applies].

This exclusion is effective 30 days from the date of this letter and shall last for a

period of STATE PERIOD.

You may, of course, continue to provide services or supplies for the effects of injuries

and occupational diseases under the Federal Employees' Compensation Act, if

permitted by your State and local licensing agencies. However, payment is the

responsibility of the patient or consumer and will not be reimbursed by this Office.

You may request a hearing on this decision by writing to the undersigned within 30

days of this letter. If such request is timely filed, the decision to exclude will be

stayed. No hearing will be scheduled if the request is received after 30 days. Your

timely request will be forwarded to the Department's Chief Administrative Law Judge

for assignment.

A request for a hearing should contain (1) a concise notice of the issues on which

you desire to give evidence at the hearing, (2) any request for a more definite

statement by this Office, (3) any request for the presentation of oral argument or

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evidence, and (4) any request for a certification of questions concerning professional

medical standards, medical ethics or medical regulation for an advisory opinion from

a competent recognized professional organization or Federal, State or local

regulatory body.

Reinstatement after exclusion is not automatic. You may request reinstatement as a

provider after the period of exclusion has expired, or after one year, whichever

occurs first. Any request for reinstatement should be addressed to the Director for

Federal Employees' Compensation, U.S. Department of Labor, Office of Workers'

Compensation Programs, 200 Constitution Avenue, N.W., Room S-3229,

Washington, D.C. 20210.

The application for reinstatement should contain a concise statement of the basis for

any application and should be accompanied by supporting documents and affidavits.

The request for reinstatement may include a request for oral argument, but such

argument will be allowed only in unusual circumstances where it will materially aid

the decision-making process. The Director will order reinstatement only in instances

where such reinstatement is clearly consistent with the ultimate goal of the

regulations under which this action is taken, to protect the FECA program against

fraud and abuse. To satisfy this requirement, the provider must furnish reasonable

assurances that the basis for the exclusion will not be repeated.

Sincerely,

REGIONAL DIRECTOR

CHAPTER 3-0900 - ADMINISTRATIVE MATTERS

TABLE OF CONTENTS

Paragraph and Subject Date Trans. No.

Table of Contents 11/98 99-06

1. Purpose 10/90 91-02

2. Obtaining Outside Medical Services 10/90 91-02

3. Release of Medical Information 10/90 91-02

4. Complaints Concerning Medical Care 10/90 91-02

5. Fees for Medical Services 10/90 91-02

6. Case Maintenance and Handling 10/90 91-02

7. Effect of Claims Actions on Entitlement to

Medical Benefits 10/90 91-02

8. Time Loss for Routine Medical Appointments 11/98 99-06

Exhibits

1. Sample Recruitment Letter and Reply—

Second Opinion Examiner 12/94 95-04

2. Sample Follow-Up Letter--Second Opinion Examiner 12/94 95-04

3. General Information for Physicians, Form CA-21 12/95 95-04

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(Link to Image) Pages 1-2

4. Sample Transmittal Memorandum--

Case File Reviewer 12/94 95-04

5. Sample Memorandum of Agreement--

Case File Reviewer 12/94 95-04

3-0900-1 Purpose

1. Purpose. The work of the Medical Unit includes administrative as well as

medical aspects. The purpose of this chapter is to describe these administrative

considerations and procedures.

3-0900-2 Obtaining Outside Medical Services

2. Obtaining Outside Medical Services. Federal regulations determine the

method of compiling the roster of physicians from whom second opinion specialists

and case reviewers will be selected. The requirements include public notice or other

recruitment methods to advertise OWCP's need for and willingness to purchase

certain medical consultation services; broad methods of distribution so that every

qualified provider who wishes to participate has an opportunity to do so; and written

agreements specifying the nature of services to be performed and the terms of

purchase, so that the provider may be held accountable for any failure to provide the

service as promised.

a. Recruitment. District offices may use various methods of recruitment,

including:

(1) Writing or telephoning physicians listed in national or local

rosters of medical specialists.

(2) Contacting officers of local medical and hospital associations,

departmental chairpersons of medical schools, hospital staffs, and

other government agencies which employ physicians. The letters

shown in Exhibits 1 and 2 may be used for this purpose.

(3) Advertising through county medical societies or

through publications of other organizations.

The District Medical Director (DMD) is responsible for conducting the

district office's outreach function (see Chapter 3-200.3). Form CA-21

(Exhibit 3 (Link to Image)) may be used to provide prospective

consultants with general information concerning their role and the

program.

b. Insufficient Number of Physicians. If too few physicians respond to

recruitment efforts, the list may be expanded by drawing on other sources.

For example, the DMD may call or write physicians known to be available in

the area on a case-by-case basis. As long as all qualified physicians who

express willingness to examine claimants or perform case reviews receive an

equitable share of referrals, the Office may freely use other physicians who

did not respond to the recruitment or advertisement. Where specialists are

scarce, second opinion examiners or case reviewers need not be Board-

certified or Board-eligible.

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c. Acceptability. The DMD should provide information to the District

Director (DD) about the responsiveness and professional qualifications of

physicians who apply to provide services and about an appropriate range of

fees. The contracting officer (or designee) should interview each physician by

telephone or in person to fix a reasonable cost or range of fees per service,

and to establish a method whereby the physician will obtain referrals.

Physicians who will review case files may obtain them by mail or in person

from the district office. The contracting officer should avoid committing the

Office to a minimum number of referrals to any one physician. The DMD

should, however, be able to provide a verbal estimate of the workload.

If a physician with a demonstrably poor record of timeliness, responsiveness,

or completeness of reports asks to provide service, the DMD should contact

the physician and explain the program and its requirements, stressing the

need for promptness, the standards for reports and the importance of

responsiveness to questions. If interest continues, the physician may be

asked for an opinion on one or two cases prior to contracting so that his or

her understanding of the program and the kinds of issues on which opinions

are needed may be demonstrated. Physicians may be advised that the

reports are insufficient for the Office's needs, or that the Office has a

sufficient number of specialists for present workloads. The district office

should, however, avoid writing extensively critical letters to physicians.

d. Written Agreements. All physicians who regularly review cases for the

Office should be placed under written agreement. Physicians who complete

such agreements should not be asked to perform referee examinations while

the contract is in force, and office records should be annotated to show the

physicians in this category.

The contracting officer within each region is the Regional Director (RD), who

is responsible for ensuring that they procedures are followed. The authority

to sign agreements with physicians may be delegated in writing to the DD,

but no further delegation is permitted. Sample agreements are shown in

Exhibits 4 and 5.

e. Record-Keeping. The Medical Management Assistant (MMA) should

maintain careful records in order to demonstrate compliance with these

procedures. The following should be documented:

(1) Recruitment efforts and responses to them;

(2) Use of each physician responding, or reasons for not doing so;

(3) Contractual agreements with all physicians serving as case

reviewers.

3-0900-3 Release of Medical Information

3. Release of Medical Information. While Federal regulations require the Office

to maintain the confidentiality of records under its jurisdiction, they also provide that

the claimant may have access to records pertaining to him or her as long as the

information released will not be harmful. In most instances the regulations prohibit

release of information to others unless the claimant has given written permission to

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release the records.

a. Release by OWCP. With written consent from the employee, the CE

may release medical records to the representative, a private insurance

company, a welfare agency, etc. If the CE believes that information

contained in the records may be embarrassing or damaging to the claimant,

the case will be referred to the DMA for review to determine whether release

is advisable. Extreme caution should always be exercised when considering

release to any party of medical information containing diagnoses or

impressions of sexual deviation, drug addiction, alcoholism, psychotic

conditions, or conditions resulting from self-abuse. The DMA may suggest

release to the employee's treating physician for interpretation.

(1) Claimant or Representative. The DMA may be asked to render

an opinion whether release of medical records would have an adverse

effect upon the claimant. If so, the information will normally be

released only to the employee's physician for interpretation.

(2) Claimant's Physician. When the claimant's attending physician

wishes to study x-rays, electrocardiograms, slides, etc., made by

another physician, clinic, or hospital, it is proper to authorize such

review. These materials may be sent to the requesting physician by

certified mail with the understanding that measures will be taken to

avoid loss in transit and to return the materials promptly.

(3) Medical Departments of Other Federal Establishments. It is

customary to furnish copies of medical reports of authorized

examinations in connection with an injury to medical departments of

other Federal establishments upon request.

(4) Office of Personnel Management (OPM). Medical information,

usually in the form of copies of pertinent medical records, may be

furnished the Office of Personnel Management upon request.

(5) Social Security Administration. Medical information, usually in

the form of copies of pertinent medical reports, may be furnished the

Social Security Administration upon request.

(6) Attorneys in Third Party Cases. All requests for medical

information on third party cases shall be referred to the CE designated

to handle such cases.

(7) Insurance Companies. Information may be released to an

insurance company when the request is accompanied by a signed

release from the employee.

Reports containing confidential information gathered by such agencies

as the Federal Bureau of Investigation and the Office of the Inspector

General remain the property of those agencies. Neither the reports

nor communications concerning them may be disclosed outside OWCP

without prior approval. Requests for access or disclosure of such

reports or communications should be referred to the agency which

generated the report.

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Similarly, OWCP should not release reports labeled confidential by

their authors. The requestor should be advised to contact the

originator of such a report concerning its release.

b. Release of Medical Information by Others. The CE and DMA may be

consulted by employing agencies, medical providers and others concerning

the propriety of release of information pertaining to FECA claims. The

following guidelines pertain to release of such information by parties other

than OWCP:

(1) Medical Providers. Physicians providing medical services on

OWCP authorization may release medical information to the claimant

and his or her representative without OWCP approval, but they may

not release such material to other parties, and they are not permitted

to use such information for teaching purposes or to abstract it for

publication without the specific approval of OWCP. If such release has

occurred, the DMA should contact the physician and advise him or her

that medical records pertaining to OWCP beneficiaries are privileged

and confidential and may not be released to others without the specific

approval of OWCP.

(2) Employing Agencies. The regulations state that all records,

statements, and reports made in connection with a claim for

compensation are the official records of OWCP and are not records of

the agency, establishment, or department making or having the care

or use of such records. Information needed for the official purposes of

any department, agency, or other establishment of the Government

may be disclosed if the employing agency certifies that such

information will be used exclusively for official purposes.

(3) Federal Facilities. Federal hospitals and clinics may release

medical information relating to OWCP beneficiaries from their records

to medical officers of other Federal establishments without OWCP

approval when requested for assistance in job placement or follow-up

medical services. They may also release clinical information without

OWCP approval to physicians for their assistance in caring for the

patient. In general, Federal medical facilities may release medical

information consistent with their responsibilities to safeguard the

privacy of employees and protect sensitive information.

Any correspondence concerning medical care and related subjects will be prepared

for the signature of the DMA where the district office has a full-time DMA. If the

office has only a WAE (when actually employed) physician, correspondence will be

prepared for the signature of that physician. The WAE physician will sign the

correspondence or may designate the MMA to sign it using the physician's name.

3-0900-4 Complaints Concerning Medical Care

4. Complaints Concerning Medical Care. The DMA may be asked to comment on

complaints about the quality of medical care or about medical bias or discrimination.

Complaints may range from minor matters such as prolonged waiting periods prior to

examination by a particular physician to more serious problems which may

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potentially lead to malpractice or assault and battery suits. The CE is responsible for

answering such complaints, but the DMA's professional expertise may be needed to

prepare the response. Complaints Concerning Medical Care:

a. Medical Management. If a question arises concerning the attending

physician's medical management of the case, the DMA should request

discussion of the medical problem involved.

b. Guidelines for Attending Physician. In response to a complaint, the DMA

may wish to seek consultation with experts in specialized fields in order to

provide the attending physician with guidelines or to determine a further

course of action with regard to medical care. In taking this action, the DMA

should not mention any possible transfer of care to the specialist at a later

date. Otherwise, the implication of bias may arise. The attending physician

must be advised of the contemplated action and told that the findings will be

made available to him or her.

Exclusion of medical providers is discussed in Chapter 3-800, while transfer of

care to another physician is addressed in Chapter 3-300.

3-0900-5 Fees for Medical Services

5. Fees for Medical Services. The Office maintains a fee schedule for certain medical

services and supplies. The amounts payable are determined by assigning a value to

each procedure which represents the relative skill, risk, and time required to perform

it and according to whether it is medical, surgical, pathological, or radiological. Each

value is then multiplied by a geographical index figure which represents the cost of

medical care in the locality where the service is provided. Not all services are

covered by the fee schedule, however, and if charges for a service which is not

included appear to be unreasonable, the CE or Benefit Payment Clerk (BPC) may

refer the case to the DMA for advice.

a. Determining Reasonableness. If the DMA cannot justify the charges on

the basis of medical complications or other complexities of the case, either

from information of record or through correspondence with the physician, the

DMA should consult the local medical society for assistance in assessing the

reasonableness of the charges. Fees higher than those charged the general

public in the area for similar services will not be allowed without written

justification in the case record and may be grounds for excluding the provider

(see Chapter 3-800).

b. Services Not Rendered. Payment of medical expenses is made on the

basis of services rendered. The law makes no provision for payment of

services not rendered or for missed appointments except where OWCP

scheduled the appointment. Payment may, however, be made to a physician

for review of a file and preparation of a report.

c. Lost Wages. An employee who loses wages in undergoing examination or

treatment authorized by OWCP may be reimbursed for these wages. The

employee must submit a statement certified by the employer which shows the

exact period of time and the total amount of wages lost. The statement must

also furnish information needed to compute the amount of wages lost, such

as rate of pay per hour or per day. Lost wages are paid only for the time

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needed for examination or treatment and travel needed to obtain it.

3-0900-6 Case Maintenance and Handling

6. Case Maintenance and Handling.

a. Telephone Conversations and Personal Interviews. A written

memorandum which provides a brief resume of the discussion must be

prepared with respect to all substantive telephone conversations and personal

interviews relating to OWCP claims (though not for brief, simple responses

consisting of information about the program or the claim). Form CA-110,

Report of Telephone or Office Call, may be used for this purpose. This does

not apply to informal discussions with other members of the OWCP staff.

b. Memoranda and Notations by DMA. Material for inclusion in case files

will be carefully worded in order to prevent any appearance of bias. Typed

memorandums must bear the full signature of the DMA in red ink, unless the

MMA signs for the DMA. The DMA's handwritten memorandum and notation

will also be signed with red ink.

c. Underscoring. Annotation of medical reports contained in the case file

is not permitted as it improperly focuses attention on certain parts of the

report at the expense of others and may result in bias. Where the DMA feels

such emphasis is necessary, he or she should prepare a memorandum for the

file.

d. Order of Pages. Any pages removed for photocopying or

other reasons should be replaced in the file in the sequence found. The order

of documents numbered for the Employees'

Compensation Appeals Board should not be disturbed.

e. Mailing of Case Records. The Branch of Records and Files is

responsible for mailing the contents of case files from OWCP. They are to be

sent by certified mail.

f. X-rays, Electrocardiograms, and Slides. Reports of x-ray and other kinds

of tests are usually sufficient for determining medical issues, and it is rarely

necessary to obtain the actual films, tracings, etc. Occasionally, however, the

DMA may need to obtain such evidence for proper evaluation of the case. If

so, it must be sent and returned by certified mail. All x-rays received in

OWCP will promptly be referred to the DMA and returned to the sender as

soon as they have served their purpose. If the sender cannot be identified,

the x-ray will be referred to the present or latest attending physician and the

injured employee notified.

3-0900-7 Effect of Claims Actions on Entitlement to Medical Benefits

7. Effect of Claims Actions on Entitlement to Medical Benefits.

a. Lump Sum Settlement. The receipt of a lump sum settlement for

disability does not bar the claimant from receiving medical examination and

treatment at OWCP expense.

b. Third Party Cases. An employee who has made a recovery from a

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third party is not entitled to treatment at OWCP expense until the remaining

credit has been exhausted. Prior to authorizing medical care in such cases,

the MMA should check with the designated CE to ensure that the OWCP will

pay further medical expenses. When the Office of the Solicitor advises that a

court hearing is imminent, all action must be held in abeyance pending the

outcome of the suit. If a dire medical emergency exists, the Director for FEC

should be contacted for instructions.

3-0900-8 Time Loss for Routine Medical Appointments

Time Loss for Routine Medical Appointments. As a rule, no more than

four hours of compensation or continuation of pay should be allowed for

routine medical appointments. Longer periods of time may be allowed when

required by the nature of the medical procedure and/or the need to travel a

substantial distance to obtain the medical care.

3-0900 Exhibit 1: Sample Recruitment Letter and Reply--Second Opinion

Examiner

Dear NAME OF PHYSICIAN:

The Federal Employees' Compensation Program is seeking physicians in your area to

perform medical evaluations of Federal employees with traumatic injuries or

occupational diseases.

As you may know, our program is responsible for providing medical and salary

replacement benefits for Federal workers found to have work-related injuries or

diseases. It is a non-adversarial system which relies on the medical community, not

only for the treatment of our claimants, but also for the evaluation of the medical

aspects of our cases. Medical evaluations are used by our claims examiners to

adjudicate compensation claims properly and to manage them effectively.

A second opinion evaluation involves the physical examination of the worker, the

review of the claim file and the submission of a written medical report answering

specific questions posed by the claims examiner. In the report, you will be asked to

give your opinion on issues such as the etiology of the condition and its relationship

to the workplace, treatment, prognosis, and the assessment of any resulting physical

impairment.

The program reimburses these services in full and, because these bills are subject to

prompt pay rules, we are committed to process your bill within a short period of

time.

Should you be interested in providing these services, please complete and mail the

enclosed form. If you desire additional information or have any questions or

comments regarding these services, please do not hesitate to call NAME on PHONE

NUMBER.

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133

Sincerely,

REGIONAL DIRECTOR

Dear REGIONAL DIRECTOR:

I would like to perform medical evaluations for the Federal Employees' Compensation

Program. I am Board eligible ( ), Board certified ( ) in .

Sincerely,

(Signature)

(Print Name)

Office address(es)

____________________________

Office telephone number(s)

Tax identification number

(EIN number)

3-0900 Exhibit 2: Sample Follow-Up Letter--Second Opinion Examiner

Dear NAME OF PHYSICIAN:

Thank you for agreeing to perform medical evaluations for the Federal Employees'

Compensation Program.

Please find below some details about our program, its requirements and claims

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processing system which may be of help to you and your office staff.

A. SCHEDULING

1. A member of our district office staff will call your office to arrange the second

opinion examination. Generally, we prefer the actual examination to take place

within 15 business days of this initial notification. If the claimant does not keep the

appointment, please notify us at once.

2. We rotate medical evaluations among the physicians in the area who agree to

perform these services. For this reason, some time may elapse between referrals.

B. BILLING

1. The program reimburses second opinion examinations in full. According to

your billing practices, this may include your usual fee for a consultation as well as

the time spent in reviewing the claimant's medical file, and any clerical time spent in

typing the report. You may wish to itemize these charges in the bill.

2. Our prompt pay rules require that your bill be processed within 30 days. To

ensure that your bill is indeed processed within this period of time, please be certain

to use the billing form (HCFA-1500) enclosed with the case file. If this form is not

used, we may have difficulty identifying your bill as one subject to the prompt pay

rules and reimbursement may be delayed.

C. CLAIMANT'S FILE

1. You will receive photocopies of pertinent material from the original case file.

These need not be returned to the district office.

2. Our files are arranged in chronological order, with the most recent material at

the top of the file. If you need to remove a page from the spindle in order to

examine it, please be sure to replace it where originally found. Also, please refrain

from making notes in the margins of the reports and underlining any material in the

file. We will try to identify the medical material for your attention.

D. MEDICAL REPORT

1. A complete medical report should be submitted to our district office within 15

business days of the actual second opinion examination.

2. The medical report should contain a brief synopsis of the clinical history of the

claimant, a description of the physical findings and, most importantly, complete

answers to all specific questions posed by the claims examiner. Should you find any

question unclear as to wording or purpose, please contact our district office for

clarification before answering the particular question. This may minimize the need

for additional correspondence from the claims examiner.

3. Answers to the claims examiner's questions, particularly in the areas of

etiology and work-relatedness, should be accompanied by an explanation or

"rationale"; unsupported, brief (yes or no) answers do not meet the needs of the

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135

program. The explanation must be sufficiently clear that other reviewers, including

non- medical staff, can see how the medical decision was reached. References from

the medical literature may be used as part of the explanation.

4. In answering the claims examiner's questions, please be as definite as the

medical findings in the case allow. Expressions such as "reasonable probability" and

"likely" are acceptable to the program. In contrast, wording such as "might be due

to" or "may have been caused" are too imprecise to support a claims decision.

If, while providing these services, problems or questions arise regarding a particular

case or the program as a whole, please do not hesitate to call NAME on PHONE

NUMBER. We will be glad to work with you to resolve any issues as they arise.

When contacting us to discuss a problem related to a compensation case, please

have the claim file number available.

Again, we appreciate your cooperation and look forward to your participation in our

program.

Sincerely,

REGIONAL DIRECTOR

3-0900 Exhibit 3: General Information for Physicians, Form CA-21 (Link to

Image)

Dear NAME OF PHYSICIAN:

Thank you for agreeing to perform case file reviews for the Federal Employees'

Compensation Program.

Four copies of the Memorandum of Agreement are enclosed. Please sign three

copies of the agreement form and return them together with your fee schedule to

this office. We will then advise you when evaluations of case files are needed.

All medical opinions must contain detailed supporting rationale, based on actual

findings and accepted medical opinion. Unsupported conjecture and speculative

judgments cannot be accepted. Evaluations of percentage loss or loss of use of a

member or function of the body for schedule award purposes must be made

according to the AMA Guides, as far as possible. OWCP will provide further guidance

for preparing medical reports as required.

No excerpts may be made from compensation files, and no case histories may be

used for publication of any papers or books or in lectures without written permission

of the Director, OWCP.

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136

A provider under this agreement is an independent contractor and is not covered

under the provisions of the Federal Employees' Compensation Act.

If you are currently providing a second opinion or referee evaluation to this office

concerning any claimant, please so advise us, indicating the claimant's name and file

number.

Again, we appreciate your cooperation and look forward to your participation in our

program. If you have any questions, please contact NAME at TELEPHONE NUMBER.

Sincerely,

REGIONAL DIRECTOR

Enclosure: Memorandum of Agreement

3-0900 Exhibit 5: Sample Memorandum of Agreement--Case File Reviewer

I. Introduction

This agreement provides for obtaining medical opinions required to determine

entitlement to compensation under the Federal Employees' Compensation Act.

Case files reviews and evaluations of medical evidence are needed when the medical

evidence of record is not clearly sufficient to support entitlement to benefits being

claimed. In such circumstances, the case file is referred to a specialist in the

appropriate field for an evaluation of the findings, diagnosis, and conclusions given

the medical reports of record.

II. Services to be Provided

The physician shall review the medical reports and test results of record, the

Statement of Accepted Facts prepared by OWCP, and any other pertinent

information, and shall answer fully and with medical rationale each question posed

by the OWCP. If the issue is degree of permanent impairment of a schedule member

of the body, the physician shall include the date of maximum improvement and shall

show how a percentage of impairment is derived in accordance (as far as possible)

with the American Medical Association's Guides to the Evaluation of Permanent

Impairment.

III. Reports

A full response to each question posed, with rationalized conclusions, shall be

returned with the case file to the OWCP within 15 days after receipt by the reviewer.

IV. Method of Billing and Payment

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Billings will be submitted on the form provided in each individual case, together with

the physician's report. Fees will be paid in accordance with the negotiated fee

schedule.

V. Fee Schedule

The basic fee for review of the file and narrative medical report is $00.

VI. Termination

This agreement may be canceled by either party upon thirty (30) days' written

notice, and return of all OWCP materials.

VII. Security of Files

The physician or medical facility agrees that OWCP files and related material are to

be treated in a confidential manner and made available only to individuals who need

the files and other material to provide the services described in the agreement.

OWCP files and related material will not be reproduced for any reason. When not in

actual use, OWCP files and related material will be kept in secure storage under lock

and key accessible only to those individuals who have a need for the files and related

material for the purpose of providing services under this agreement. OWCP files and

related material remain the property of the U.S. Department of Labor. This

agreement confers no property rights in OWCP files and related material on the

physician or medical facility providing service.

Contracting Officer Physician or Responsible Officer

U.S. Department of Labor (Type name and address below)

Washington, D.C. 20210

I am/am not currently providing treatment to beneficiaries of the Federal Employees'

Compensation Act to the best of my knowledge. (If yes, provide a list of names.)

Physician's Employer Identification Number, or SSN, if not incorporated. (Show

number under which payments should be reported to the Internal Revenue Service.)

State in which licensed:

State Board License Number: Expiration Date:

FECA PT3 PR 700

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