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Friday, March 25, 2011

FECA Manuals

When claimant's begin the claims process with the OWCP, they tend to believe what they're told by their Claims Examiners, (CE's) and their Agency, and later find that the information is less than truthful or completely inaccurate, sometimes to the detriment of their claim. It's understandable that a claimant would believe their CE and/or Agency, why wouldn't you?, you were hurt on the job and these are the people assigned to help you, it seems reasonable they'd know what they're doing. The problem is, most claimant's have never been through the OWCP process, some don't even learn of OWCP's existence until their claim is filed and by the time they figure out the information they've been given is wrong, they have to play catch-up to fix it.

Unfortunately, no one is going to come to your rescue. You must be your own advocate in the OWCP process and in order to do that, you must know the rules. How can you know the rules, if you don't read the rule book? 

The FECA Manuals are the most important weapon an OWCP claimant has. These Manuals are the rule books of the game, the rules everyone, including your CE, your Agency and you must follow. A claimant cannot fight an OWCP decision, conclusion or opinion without the FECA Manuals. Flying blind or just winging it with OWCP is going to end up with denials from OWCP and/or financial and mental frustration while dealing with the injuries you've suffered. This is not a good place to be.

OWCP and your Agency are required to follow the FECA Manuals but the sad fact is, they often misinterpret or just plain ignore them. This works in a claimant's favor if the claimant takes the time to read the FECA Manuals. If you're familiar with the FECA Manuals, the errors of the CE's or Agency's 'wisdom' will stand out. If you receive a letter, decision or any documents from OWCP or your Agency and you see errors or something just doesn't sound right,  then it's a good bet you need to look in the FECA Manuals. You don't have to read the Manuals cover to cover or become an expert, but you should read the parts of the FECA Manuals that pertain to your situation.

When you're a claimant in the OWCP system, there are circumstances you have no control over; OWCP-directed medical examinations, vocational rehabilitation, wage earning capacity determinations, job offers, etc...and although you must cooperate during these situations, OWCP has a responsibility to follow its own procedures. If OWCP doesn't follow the FECA Manual, you can use that to your advantage to overturn whatever decision OWCP has made.

For example, if you've been placed in vocational rehabilitation, read FECA part 2 at 2-0813. If OWCP denies your claim because causal relationship wasn't established, read FECA part 2 at 2-0805. Whatever your situation, there's a corresponding FECA chapter that pertains to you.

Finding what you're looking for in the FECA Manuals isn't hard to do. At the beginning of each FECA Manual there's a List of Chapters that shows you exactly what the chapter covers and the section where you can find it. It's as easy as scrolling down the page to find what you're looking for. If you don't see what you're looking for immediately, or you want to search deeper, you can search by typing what you're looking for into the search bar at the top of the page.

Once you've confirmed OWCP or your Agency did not follow the rules of the FECA Manuals, you must bring it to OWCP's attention. It's not enough to tell OWCP there's an error, you must show them the errors. In most cases, OWCP won't just fix a mistake without a little push from you or in some cases, a shove. The best way to do this is to quote the incorrect information you received and then cite and quote the FECA Manual passage that proves the error.

The FECA Manuals are not just for OWCP to use against you. You can and should use them against OWCP and/or your Agency if they don't follow those same rules. OWCP counts on you not knowing what's contained in the FECA Manuals, it makes their job easier if you don't know they've made a bad decision, if you blindly follow whatever they tell you. Don't be afraid to throw the FECA Manuals back at OWCP or your Agency. You can't get in trouble for bringing errors to their attention. OWCP expects you to abide by the rules of the FECA Manuals, you should expect them to do the same.  
You can find parts one and two of the FECA Manuals on the "Links" page.

Wednesday, March 23, 2011

Narrative Reports; Your Physician

At some point during your OWCP claims process, you're going to need a narrative medical report from your physician. Your claim won't be accepted without a proper narrative.  Physician's who don't regularly write reports for OWCP have little or no idea what OWCP requires in a narrative report. Today, we're going to learn about the requirements of a proper narrative report.

A detailed narrative report is time consuming for your physician. You should make your physician aware that s/he can charge more for the detailed narrative due to the extensive nature of the report.

Everything that goes to OWCP must have Your Name, Claim Number(s) and Date(s) of Injury, including anything submitted from your physician. You will need to supply your physician with this information so it can be included in their report.

The FECA Manual part 2 at 2-812-6(a) Content of Medical Reports states:
"Regardless of whether the CE contacts the physician or the claimant, the medical report should include:
(1) The date of most recent examination.
(2) Results of recent objective testing.
(3) Physical examination findings.
(4) The diagnosis of any conditions present.
(5) A well reasoned medical opinion supported by the physical findings and objective testing as to whether the current condition(s) is related to the employment.
(6) The claimants work restrictions, including a completed Form OWCP-5 if applicable.
(7) The type and frequency of medical treatment being provided or recommended."
You can find part 2 of the FECA on the "Links" page.

Let's take these requirements one by one:

(1) The date of most recent examination.

This is self-explanatory, it's the most recent date your doctor examined you;
(2) Results of recent objective testing.
This includes MRI-s, X-Rays, EMG's, EKG's, EEG's, Blood tests, etc... In other words, any diagnostic test that confirms your diagnosis. Objective testing is any test you can't fake. Your doctor also needs to state what abnormal findings came from the results of your test. For example, your MRI shows a herniated disc at C4-5, your X-Ray showed your Right thumb was broken in two places, one break being a compound fracture. 
Your physician should be specific about the test results. If the test results show multiple issues, your physician can state that the test showed multiple abnormalities and s/he has attached a copy of the test results with his/her report. If your physician is going to attach the test results (and s/he should) it must be mentioned in your physician's report that a copy is attached.
If the test results confirm the reason the physician sent you for the test, this should also be stated. For example, The abnormal results of the 00/00/0000 MRI of the Right knee confirm the diagnosis of Lateral Meniscus tear and ACL tear of the Right knee.
If it applies to your condition(s), your physician should be specific about the LEFT, RIGHT or BILATERAL body part EVERY time that body part is mentioned in their reports.
If you've had multiple tests, you can make it easier and help your physician by listing the dates and facilities you had your test(s) and provide a copy of the test results for easy reference or to attach to your report. You should list them in dated order beginning with the most recent test results;
(3) Physical examination findings.

This is Range of Motion, (ROM), Reflexes, Grip/Pinch strength, Straight Leg Raises, Gait derangement, Palpitations, Limb length discrepancy, Swelling, Bruising, Muscle Atrophy, etc...The type of tests your physician performs depends on the type of physician you're seeing and your specific condition(s).
Your physician should list out his/her findings in specific detail. For example, if the test is negative or positive. If the physician finds spasms, tenderness, firmness, weakness, etc...these results should be listed. If measurements are taken, the measurement results.
Any test performed on your upper (arms) or lower (legs) extremities, ears or eyes should be identified by either Right, Left or Bilateral. If Range of Motion is diminished, your physician should list those findings as specifically as possible;
(4) The diagnosis of any conditions present.

The diagnosis must also include the corresponding ICD-10 code. Your physician will be very familiar with ICD-10 codes. The ICD-10 code is the medical diagnosis code (a number)that identifies your medical condition. 
Once your claim is accepted by OWCP, your accepted condition(s) will be identified by ICD-10 codes. You can locate your OWCP accepted ICD-10 codes on the ACS site. Once you log in, click on CQS (Customer Query System) on the left side of the screen. Enter your claim number when the CQS screen comes up. Your accepted conditions will be listed in the upper right hand corner of the page. You can find the ACS and ICD-10 web sites on the "Links" page;
(5) A well reasoned medical opinion supported by physical findings and objective testing as to whether the current condition(s) is related to the employment.

A well reasoned medical opinion is the most important part of your medical narrative, especially if your claim has not yet been accepted. Your physician must state how s/he came to his/her medical opinion regarding your medical conditions. You physician must be as specific as possible. This part of your report is crucial and I've included more information about it later in this post;
(6) The claimant's work restrictions, including a completed Form OWCP-5 if applicable.
OWCP sends every second opinion or IME physician a Form OWCP-5, but very rarely sends your physician an OWCP-5 to complete. However, there is no 'rule' that says your physician cannot complete an OWCP-5. You can print out an OWCP-5 and bring it with you for your physician to complete and attach to his/her report. If your physician is attaching an OWCP-5 to his/her report, s/he should state it in the report. For example, your physician should state, they've attached a completed OWCP-5 which indicates your physical restrictions.
An OWCP-5 lists your physical restrictions and are by type of condition. For example, an OWCP-5c is for musculoskeletal conditions, an OWCP-5a is for emotional/mental conditions. So, make sure you print out the proper form for your condition(s). You can find OWCP-5 forms under Forms on the "Links" page.
(7) The type and frequency of the medical treatment being provided or recommended.
Treatment being provided is any treatment you've already received or are receiving, such as Physical Therapy, Medications, Braces, Nerve Blocks or other Injections, etc...
Your physician should not only list the treatment(s), but also the details of the treatment. For instance, the name of the physical therapy facility and the frequency you attend and why you're attending. For example, Ms. Doe attending physical therapy at XYZ Physical Therapy twice per week beginning 00/00/0000 to maintain range of motion in the Left shoulder. 
If you're receiving medication, your physician should list every medication by name, the dosage, frequency and why it's prescribed. For example, Mr. Doe is prescribed Diazepam 5mg 3 times per day for pain and spasms. If there were outpatient procedures, your physician should state the name of the facility which performed the procedure, what the procedure was and the results of the procedure. If there is a report of the out patient procedure, a copy should be provided to your physician.
If you've had multiple treatments, you can help your physician by providing them with a list of the treatment you've received to date to make it easy to incorporate into their report. A copy of the report should also be attached to your physician's report and again, your physician must state a copy is attached.
If your physician is recommending treatment, then s/he should state not just what treatment you require, but the name of the facility in which it will be performed (if known), how often s/he recommends the treatment and why the physician believes the treatment may help you. For example, Mr. Doe requires physical therapy at XYZ Physical Therapy 3 times per week to maintain range of motion in the Left knee.
A well reasoned medical opinion is crucial to your narrative report. What the above section of the FECA Manual doesn't state is that your physician needs to state what Agency you work for, what your start date was, what position you held on the date of your injury and the physical requirements of your job. You should provide a description of the physical requirements of your job so your physician can refer to it in his/her report. Your physician should attach a copy of the job description and needs to state s/he is attaching a copy of the job description.

You should bring your physician a copy of your job description. If you don't have an official job description, your Agency may be able to provide one to you. If not, you can get your official job description and physical requirements from O*NET the link for O*NET is on the "Links" page.

If you filed a traumatic injury claim, your physician must be specific how you were injured. S/he must state you were in performance of your regularly or specially assigned duties and what Agency you were working for when the injury occurred. For example, On 00/00/0000 Ms. Doe was in performance of her regularly assigned duties as a clerk with the U.S. Postal Service during an 8 hour shift while having no medical problems when she fell off a ladder onto a concrete floor. Ms. Doe fell approximately 4 feet landing on her Right side, breaking her Right femur, shattering her Right knee cap and bruising her Right shoulder. The 4 foot fall and resulting impact of landing on the concrete floor is what caused the Right femur to break, shattered the Right knee cap and bruised the Right shoulder. Prior to the 4 foot fall off the ladder, Ms. Doe's Right femur, Right knee cap and Right shoulder were not injured, broken or fractured and she was not seeking medical treatment or taking any medication for any of these conditions. It is reasonable the 4 foot fall off the ladder landing on the concrete floor is what caused the diagnosed injuries to Ms. Doe's Right femur, Right knee cap and Right shoulder.

Your physician cannot be too specific in narrative reports to OWCP.

It seems obvious to all of us that falling 4 feet off a ladder will injure you, but if your physician isn't extremely specific about who you were working for and exactly how your injuries occurred, OWCP will more than likely reject the report and your claim forcing you to go back to your physician to try again.

If you've filed an occupational injury claim (CA-2), then your doctor needs to specifically state how the injury occurred. For example, your job requires you to repetitiously use the injured body part throughout the day and you've been performing the job tasks for 15 years. The 15 years of repetitively using the specific body part contributed to the acceleration of a degenerative condition. Just as with a traumatic injury, your physician must be specific how the injury was worsened by your employment.

When your physician writes a medical narrative for OWCP it's about the WHO, WHAT, WHEN, WHERE, WHY and HOW in specific detail. Your physician must report with certainty. OWCP will reject any reports stating your condition(s) "Might be" "Could be" "Maybe" related to your employment. Your doctor can use terms such as "More probable than not" "More likely than not" "With a reasonable medical certainty" "It's reasonable to conclude", etc...

Your physician should sign and date the report. OWCP will not give any weight to a report that is not signed by a physician. A physician's assistant is not a doctor under the Act and will be given no weight whatsoever no matter how detailed the report is.

Once you have a narrative report from your physician, you should send a copy of the report, test results, job description, any forms such as a completed and signed OWCP-5 with a letter to your CE. I recommend you send this delivery confirmation, certified mail or other trackable delivery system so that you have proof OWCP received the report and the documents that go with it. Your letter should state each item you're sending and the date of the item. This way you can be sure OWCP received the narrative and all the documents that were attached to the report.

Sunday, March 20, 2011

Medical Reports Part 1

So, you've been sent to an OWCP-directed medical examination and you've received your report which is less than favorable. What should you do?

In this lesson, we're going to learn what to look for to rebut your OWCP-directed medical report. This can be a second opinion examination, Independent Medical Evaluation, (IME) or even a Functional Capacity Evaluation (see the post Functional Capacity Evaluation Reports for more information on FCE's).

So, what ARE you looking for? You're looking for contradictions, inconsistencies and errors.

First and foremost, read the report over and over. When you think you've read it enough, read it again and again after that. Why? because by reading the report over and over, it becomes familiar and contradictions and inconsistencies will be more obvious to you.

After you've read your report, read your Statement of Accepted Facts, (SOAF), is the information contained in your SOAF accurate? Are the dates, claim numbers, accepted injuries, mechanism of injury, etc...correct? Does the SOAF have a current date or is it an old SOAF the CE has recycled? If the SOAF is older, have any changes occurred that are not contained within the SOAF, such as a current MRI or other diagnostic test? At the very least, your CE should have re-dated the SOAF with a current date. Otherwise, you could argue the SOAF is outdated.

OWCP-directed medical reports MUST be based on factual information. The SOAF is that information. An OWCP physician must use the SOAF as his/her frame of reference, if it's inaccurate it results in a report based on inaccurate information. Any OWCP-directed medical report that is not based on a factual SOAF can be fought. See the "Useful Stuff" page for ECAB decisions regarding inaccurate SOAF's.

Next, read the list of questions provided to the physician. Are the questions the physician answered the same questions OWCP asked?

As you read your report, look for errors. Maybe the report states you saw Dr. Smith, but you actually saw Dr. Jones. Maybe the report states you saw Dr. Smith February 12, 2010 but you actually saw Dr. Smith April 18, 2010. You're looking for factual errors. Maybe the report says you've had no diagnostic tests, but you had an MRI.

When the doctor relays your medical documentation from reports provided to him/her, is it accurate? For instance does the report indicate you had an MRI and the results showed no evidence of abnormalities but the MRI report actually states there are abnormalities? Does the report accurately report your physical limitations? For instance, your physician has you restricted to 4 hours per day with a lifting limitation of 20 pounds but the OWCP report states you're working with no restrictions, or you're working 8 hours per day, or you're able to lift 50 pounds.

Let's take a look at some examples of what you're looking for in your OWCP-directed medical report. In our examples, we're going to use information from actual second opinion and IME reports.

Example #1:
"The medical records reviewed document medical treatment beginning on June 12, 2006 for ongoing problems with the cervical spine with radiating pain into the shoulders. Although a diagnosis has been established of herniated nucleus pulposus cervical spine with cervical radiculpathy, there are no MRI studies available for review to document this."
This particular claimant was injured and treatment began in 2004, so the medical records sent to the physician were not complete. The claimant also had MRI's performed in 2005 and 2007.  However, the physician states "no MRI studies available for review".

The argument here would be that the physician was not provided a complete medical record and that the physician did not review the MRI results. Therefore, his report is not accurate or complete due to the missing records and diagnostic test results.

Example #2:
"It should be noted that the claimant was seen for Referee Examination on June, 8 2006 by Dr. Howard Shortley, who felt the claimant was working 8 hours a day with lifting restriction of 40 pounds, no driving more than 2 hours and no above shoulder work. It should be noted that I have not been provided with this report.
From review of the above medical records, it does not appear there has been any significant change in the patients conditions since June 8, 2006, when the patient was seen for Referee Examination by Dr. Shortley. Based on the above, it would be my opinion that the patient could work 8 hours a day, as opined by Dr. Shortley."
This particular claimant was not working 8 hours per day, but 4 hours per day and the lifting restriction was 25 pounds and not 40 pounds. The physician then states his opinion agrees with that of the referee physician. The crucial information here is, "It should be noted that I have not been provided with this report." The physician is giving information and agreeing with an opinion from a report he states he hasn't seen.

The argument here would be the contradictions, 40 pounds vs. 25 pounds, 8 hours per day vs 4 hours per day and most importantly, the physician's opinion is based on a report he was not provided with. As it so happens, the referee report stated the medical conditions were progressive and would probably get worse. Since the physician didn't receive a copy of the referee report, he was not aware of this opinion. It would be impossible for the physician to know what the referee opinion is because the physician wasn't provided the report that contained the opinion.

Example #3:
"A previous neck-Workers' Compensation injury occurred in 1999 that resolved in six weeks."
This particular claimant had never filed a previous OWCP claim. The argument here is inaccurate information reported by the OWCP physician.

Example #4:
"The treating physician okayed work eight hours a day."
In this case, the treating physician never released the claimant to 8 hours of work per day. The argument here is inaccurate information reported by the OWCP physician.

These are the things you're looking for when you receive your report from OWCP. You're looking for factual errors, contradictions and inconsistent reporting. This can be a complicated, confusing process at first, but if you understand what you're looking for, with practice it becomes second nature.

As we go along, we'll explore how to argue your case to attempt to overturn the weight of an OWCP-directed medical report. We'll also explore more about SOAF's and the questions OWCP provides to its physicians.