Injured employees throughout the nation have experienced denials of their workers’ compensation claims, denial of essential medical treatments, and lost wages due to denied compensation claims. In many instances, these injured workers were told by their medical providers that the doctor’s office would “take care of everything” for them, only to find themselves with large unpaid medical bills and no assistance following the denial of their claim. There are numerous wellness centers and treatment facilities that cater specifically and only to injured federal employees, marketing themselves as a “one-stop-shop” for dealing with OWCP.
However, federal workers’ compensation fraud is unfortunately a regular occurrence across the country. Examples can be readily found online. Some providers have taken advantage of injured employees by:
- failing to submit authorization requests and medical records to OWCP
- refusing to release necessary medical records to injured employees
- improperly stating an employee is disabled for the purposes of obtaining disability payments
- prescribing and billing for excessive treatment / therapies, beyond what may be advisable or permissible
- accepting kickbacks for the scheduling and providing of unnecessary medical treatment
- use of unauthorized providers such as nurses and physician’s assistants without proper oversight
Below are some best practices for use by injured employees to ensure proper treatment and acceptance of your workers’ compensation claim.
Initial Selection of Physician
Injured employees have the statutory right to select their treating physician at the time of injury. The employing Agency cannot require an employee to see a particular physician related to their workers’ compensation claim. Physicians must be enrolled, or willing to enroll, as a covered provider under FECA.
Not all physicians are equal however, and it is recommended that injured employees uses the FECA Provider Search to confirm that their physician is enrolled to treated injured federal employees. Additionally, websites like healthgrades.com can assist you in finding a reputable physician, specializing in the treatment of your injury. Always remember to confirm that your physician is an enrolled provider to prevent any billing and authorization issues.
Injured employees must also ensure that they receive treatment from a qualified physician under FECA standards. In many instances, wellness centers and facilities specializing only in federal workers’ compensation have used nurse practitioners and physicians’ assistants to treat injured workers, contrary to regulations. OWCP specifically requires that employees be under the treatment and supervision of a qualified physician, certified by the appropriate authority, such as the AMA. Where employees only receive treatment from someone other than a physician, they run a greater chance of their claim being denied.
Monitoring of Your Workers’ Compensation Claim
Injured employees have the responsibility to monitor their claim, even where they have designated a representative or where advised by their provider or facility that they will address any issues. Current federal employees may access their information via the National Financial Center (NFC) Employee Personal Page. After logging into the Employee Page, the Claimant Query System link to access workers’ compensation information can be found at the lower, left portion of the page. Injured employees who are not serviced by NFC, or have separated from federal service and want to obtain information about their OWCP case such as case status, recent compensation payment, or status of their most recent claim for compensation, may do so by using OWCP’s phone system by calling their local district office.
Employees should regularly monitor their claim for the following information:
- Claim Status – regular of the claim status is important to understanding the payment and approval of medical and compensation benefits.
- Accepted Medical Conditions – injured employees should regularly compare their diagnosed medical conditions, as noted in their medical records, to those that OWCP has accepted as being related to the work injury. Where discrepancies exist, injured employees should communicate with both the treating physician and Claims Examiner to ensure the claim is developed and/or expanded. Where the accepted medical conditions and those used by the treating physician are different, medical billing and authorizations may be denied. Compensation for periods of treatment or disability may also be denied, resulting in lost wages.
- Submission of Form CA-7 – employing agencies have 5 working days to submit Form CA-7, Claim for Compensation. This form is used for the payment of disability compensation. Injured employees should routinely monitor their claim to ensure that the employing agency submits the request in a timely fashion. It is also recommended that injured employees request and obtain a copy of the completed form from the agency to review for accuracy, especially pertaining to premium pay information and other benefits such as health and life insurance.
- Medical Billing Status – injured employees should regularly review submitted medical bills to ensure that they accurately reflect the treatment provided and that the billed diagnoses match the accepted conditions from OWCP. Where bills are denied, injured employees may find themselves with unpaid medical bills.
- Pending Authorizations for Medical Treatment(s) – injured employees should regularly review their claim to ensure that their physician has properly requested prior authorization for invasive procedures and testing such as injections, surgery, CT scans, etc. In each of these scenarios, OWCP requires a detailed medical narrative to support the approval of the procedure prior to scheduling the treatment. Where prior authorization is not obtained, injured employees may find themselves with unpaid medical bills and lost wages for any period of corresponding disability.
Employees who note inaccurate bills being submitted, such as for treatment which was not provided, or denial of medical bills for treatment related to their injury, should contact their Claims Examiner immediately. The Claims Examiner will provide any necessary guidance in order to obtain additional information required for approval. Alternatively, where fraud is suspected, injured employees may provide notice to the Department of Labor’s OIG.
Active Participation in Medical Treatment
While most injured federal employees do not have a medical background, it does not mean that you have to handle your claim in the dark. Injured employees should ask questions and document the responses from their physicians, especially pertaining to their treatment plans. Injured employees can compare their physician’s recommended treatments and procedures to reputable websites such as WebMD or MDGuidelines to determine if it is in-line with accepted medical standards. OWCP will only authorize and make payment for treatments which are in-line with accepted standards (such as those adopted by the American Medical Association).
Remember, in the end, it is always the right of the injured employee to refuse intervention by the nurse case manager. Additionally, it is also the responsibility of the injured employee to collect, review, and ensure submission of all medical records necessary to support
Submission and Review of Medical Records
OWCP and the FECA specify requirements for medical reports submitted in support of workers’ compensation claims. Medical narratives are required to support further treatment, continuing disability payments, and invasive procedures such as surgery or injections.
Many workers’ compensation providers and treatment facilities advise injured employees that they will submit all required documentation for the injured employee. However, where documentation goes un-submitted or is submitted without the required detail, it is ultimately the responsibility of the injured employee to obtain, review, and submit the required medical records.
In all claims, the injured employee is responsible for submitting, or arranging for submittal of, a medical report from the attending physician. For wage loss benefits, the claimant must also submit medical evidence showing that the condition claimed is disabling.
Best Practices
In summary, injured employees should be conscious of their responsibilities in their workers’ compensation claim, as they are the one receiving benefits. Where medical providers and facilities promote a “one-stop-shop” promise for claim management and treatment, injured employee must ensure that they employ a “trust and verify” approach to dealing with their providers. Injured employees should always ensure that they regularly:
- confirm that providers are enrolled under FECA and are submitting timely and accurate billing.
- review claim status and accepted medical conditions to ensure proper treatment and payments.
- review and submit all medical records to ensure proper treatment authorization and payments.
