Wednesday, April 20, 2011

I Feel A Rant Coming On

How many people out there reading this have noticed the exorbitant amount of money OWCP pays for its nurses, District Medical Advisors, (DMA), vocational rehabilitation counselors and physician's?

An OWCP field nurse will receive a minimum of $5,000.00 for their services. I've seen a nurse paid up to $20,000.00 for their so called services. This amount might be reasonable if the nurses actually did anything other than bill for services they do not or cannot render. A vocational rehabilitation counselor can spend an hour on your case and charge $1,000.00-$1,500.00 for their time and no one at OWCP questions the bill.

It seems to me that any claimant in vocational rehabilitation who is asked what job they want to do could respond that they want to be a vocational rehabilitation counselor. You don't have to do much and you get paid an extreme amount of money.

Recently, I saw a DMA report that consisted of one and a half pages and the DMA charged $225.00 for it. When OWCP went back for clarification, the same DMA charged an additional $225.00 for one paragraph of clarification. $450.00 for two pages. And as usual, the finished report was thrown out due to inaccuracies, inconsistencies and policy violations.

Then there's OWCP hired gun physicians. A second opinion physician can charge as much as $1,000.00 or more for a report and the Independent Medical Evaluation, (IME) physicians can charge $4,000.00 or more for their reports and receive it. Not only do they receive the full amount they charge, they get paid by "Prompt Pay" which means they get their money paid quicker than anyone else.

I'm working with a claimant right now who was sent to a second opinion and an IME. I expect both reports to be thrown out on appeal since neither is accurate or complete and neither report actually addresses the issues OWCP requested. As with any OWCP medical report, neither are up to OWCP's standards, yet OWCP has determined they carry the weight of medical evidence. One claimant, two reports with a cost of $4,900.00. And again, I expect that money will have been paid for nothing since the reports should be thrown out on appeal.

This particular IME boasts he has done 10,500 IME examinations for one company. He charged OWCP $4,250.00 for one report. If my math is right, that's $4,462,500.00 for writing medical reports that are easy to get thrown out. And remember, that's just for one company.

Think about how many medical reports are thrown out on appeal. How much money wasted for the cost of those reports only to determine later the report wasn't up to OWCP's standards. If we knew the actual figures, the amount of wasted money is in the multi-millions.

If you were a doctor, why wouldn't you exclusively write these types of reports? The money is better than a physician in private practice and you don't have to deal with those pesky patients. Of course the four million dollar price tag doesn't include the physician going to court as an expert witness or any of the reports written for other companies or the reports s/he may write for State workers' compensation, Social Security, etc...Factor in the 10 minutes to half an hour the physician spends doing his 'exam' and the profit margin to the physician really becomes clear.

Just for a minute imagine what would happen if a claimant's physician charged $650.00-$4,000.00 for one report. If it was a claimant's physician, I can almost guarantee OWCP would come after the physician for fraud, but they don't blink an eye if the physician is one of their hired guns. A claimant's physician can write a complete, thorough report and charge $200.00-$300.00 and not receive the full amount charged because OWCP determines the cost is too high. Yet OWCP's physicians seem to be able to charge any amount and receive that amount promptly and in full without any questions whatsoever.

The problem for claimant's is when a physician does these sort of reports as their exclusive way of making a living, they come to rely on the money and in order to continue on the gravy train, they must produce reports against claimants or risk OWCP dropping them in favor of a physician that will write the reports OWCP wants. The physician becomes biased. That's not my opinion, it's a fact that can be verified by searching the physicians through Employees Compensation Appeals Board, (ECAB). If you look, every physician that works regularly for OWCP consistently writes reports against claimants. In a lot of cases, the reports are contrary to all the medical evidence in the file and yet are accepted as factual by OWCP and given weight of medical evidence.

It's no wonder these people work exclusively for OWCP. Why wouldn't they? The money is way more than any amount you could make in the 'real' world. It's more than any other person in their field can make for doing the same job.

In light of the recent comments from OWCP's current Director about the cost of caring for claimant's, and how OWCP needs to cut benefits and services to claimant's because claimants receive too much, it seems the obvious choice for saving money is through OWCP's own medical personnel.

Before OWCP decides claimant's are receiving too many benefits at too high a cost, their own medical personnel should be put under the microscope and caps on their fees should be put in place. Not only would that save OWCP more money than cutting services for claimants, it just might eliminate physicians, nurses and vocational rehabilitation counselors that only work for the big bucks OWCP will pay them.

All of us have to start writing to OWCP with our complaints against the fees OWCP's medical personnel receive. We have to write complaints against the physicians, nurses, vocational rehabilitation counselors and DMA's who regularly work for OWCP and consistently go against claimant's no matter what the evidence shows. If we continue to sit back and do nothing then we will change nothing.

Tuesday, April 19, 2011

Causal Relationship; What's the Difference?

In order for your claim to be accepted, you must prove causal relationship. Causal relationship means the relationship between you, your work and the injuries you claim.

There are four ways your medical conditions can be related to your employment:

1. Direct Causation is shown through a natural and unbroken sequence resulting in the condition claimed. If you broke a bone after a fall, the broken bone is caused by the fall. If you were injured in a motor vehicle accident, the accident is the cause of the injuries. If you were attacked by a dog, the dog attack is the cause of the injuries, etc...

An unbroken sequence means that nothing interferes with the sequence of events. Nothing saves you from falling. Nothing keeps you from being in an accident. Nothing stops the dog from attacking you. An unbroken sequence means that from start to finish the events lead to injury.

Occupational injuries fall under direct causation, but are also known as "proximately caused" and the medical evidence to prove your occupational injury more than likely will require greater medical rationale in order to have your claim accepted.

Medical rationale is the HOW of the injury. For example; you fell from a height and landed on a concrete floor. When you hit the concrete floor, you broke your leg. Falling from a height and landing hard on concrete caused your leg to break. The broken leg required immediate medical attention. If you had not fallen from a height and had not landed on concrete, you would not have broken your leg and would not have required medical attention.

When it comes to medical rationale, your doctor must be specific. What is obvious to claimants and their physician's is not obvious to OWCP. There should be no question where you were, who you were working for and exactly how the injury occurred. Again, although obvious, it is not enough for your doctor to say you fell off a ladder at work and broke your leg.

Once accepted, there is no limitation on the duration or severity of the condition. As long as the medical evidence shows disability and/or the need for medical treatment, there is no time limit on how long compensation and/or medical treatment will be paid.

2. Aggravation occurs if you have a pre-existing condition and that condition is worsened, either temporarily or permanently by an injury arising in the course of your employment. For example, you have a heart condition and your heart condition is aggravated by your employment. You have degenerative disc disease and you sustain a traumatic injury which aggravates your degenerative disc disease. You have a respiratory condition and dust aggravates your condition.

A temporary aggravation involves a temporary (or limited) period of medical treatment and/or disability after which you return to your previous physical status.Compensation is payable only during the period of time the aggravation lasts. When the aggravation ends, compensation and/or medical treatment is no longer payable. A temporary aggravation involves only the aggravation and not the underlying disease. Benefits are paid only for the aggravation that made your condition worse, not the condition itself.

OWCP must determine through medical evidence a temporary aggravation has resolved. Your benefits cannot be terminated without notification and proper medical evidence. Normally, OWCP does this through one of its medical examinations.

A permanent aggravation occurs when a condition will persist indefinitely due to the effects of the work-related injury or when a condition is materially worsened and will not revert to its previous level of severity. For instance if you suffer from allergies and you were exposed to dust or fumes and the exposure to dust or fumes causes your allergy attacks to be more severe, that would be a permanent aggravation. If your spinal condition was aggravated and you lose range of motion that you don't recover, that would be a permanent aggravation. A permanent aggravation means that the worsening isn't expected to get better.

There is no additional benefit to you for a permanent aggravation, but OWCP does not like to accept permanent aggravations because it is easier for OWCP's physician's to say your temporary aggravation ended so OWCP can terminate your benefits. If your aggravation is permanent it's harder for OWCP's physician's to say there are no residuals of the aggravation. If your physician believes your medical condition was permanently aggravated, they should say so in every report.

3. Acceleration means that the injury or illness hastened the development of an underlying condition. An acceleration is when the speed in which your condition develops is faster than if you were not exposed to injury or illness. If you're young and you have a knee injury that results in a total knee replacement, your condition was probably accelerated because knee replacement is normally done when you're older. If a hectic, erratic work schedule prevents you from regular eating and your diabetes gets worse, your diabetes was accelerated by your employment. If you have a spinal injury and your degenerative disc disease which was not symptomatic, suddenly becomes severe, your degenerative disc disease may have been accelerated by your employment.

4. Precipitation is when your condition is latent and would not have developed without factors of your employment. If you have tuberculosis that is latent and you become symptomatic after an exposure at work, your tuberculosis was precipitated by the new exposure.

Like a temporary aggravation, only the work-related precipitation is compensable. Once the condition returns to a latent condition, your entitlement to benefits ends. If the condition does not return to its previous state, then there would be no limit on the duration of acceptance. In other words, as long as the condition is present, you're entitled to benefits.

You can find information about causal relationship in the FECA Manual part 2 at 2-0805-2.