Monday, February 25, 2013

Change of Physician

If the physician originally chosen to provide treatment for a work-related injury refers a claimant to a specialist for further medical care, OWCP will honor the referral as long as it is for the work-related condition. The claimant DOES NOT need to consult OWCP for approval.

If the claimant wants to change their physician, the claimant MUST submit a written request to OWCP with a list of reasons for the change along with the name, address and specialty of the physician the claimant wishes to change to. 

OWCP must review all change of physician requests.

Reasons that are often approved include transfer of care from a general practitioner to a physician who specializes or when the employee moves. 

OWCP has determined that 50 miles one way or 100 miles round trip is a reasonable distance for a claimant to travel to a physician. Requests for a new physician that are over the 100 mile maximum will probably be denied. However, if a claimant lives in a rural area or in an area without a physician within the 100 mile distance, the CE has the authority to waive the 100 mile maximum. 

If a claimant cannot find a physician within the 100 mile round trip maximum, this should be one of the reasons listed to OWCP. If this is the case, w
ith their letter requesting a new physician, the claimant should include a list of the names, address', phone numbers and specialties of any physicians that the claimant has contacted that have declined and/or refused to treat the claimant with any reason given by the physician. For example, the physician isn't taking new patients, the physician refuses to accept OWCP claimant as a patient, etc...

The retirement of a claimant's treating physician warrants a change of physician. In this case, the claimant need only notify OWCP of the physician's retirement and provide the name, address and specialty of the new treating physician.

A request by the Attending Physician to be relieved of responsibility in a case, will be granted. The physician should be asked by OWCP to provide his/her reasons for the request, report the claimant's condition at the time and ask the physician to state any further medical recommendations.

When OWCP determines medical care will be transferred, the claimant and the previous attending physician must be notified in writing.

The ECAB states:

The Board has recognized that OWCP, acting as the delegated representative of the Secretary of Labor, has broad discretion in approving services provided under FECA.  OWCP has the general objective of ensuring that an employee recovers from his/her injury to the fullest extent possible in the shortest amount of time.  OWCP therefore, has broad administrative discretion in choosing means to achieve this goal.  The only limitation on OWCP’s authority is that of reasonableness.  

Abuse of discretion is generally shown through proof of manifest error, clearly unreasonable exercise of judgment or actions taken which are contrary to both logic and probable deductions from established facts.  It is not enough to show merely that the evidence could be construed to produce a contrary conclusion (The Board cites: Daniel J. Perea, 42 ECAB 221 (1990)).

Other information about physicians:

A claimant is entitled to choose the initial physician or facility for treatment of their injury as long as the provider meets OWCP's definition of "physician" and has not been excluded from payment by OWCP. 

Physicians employed by or under contract to the Agency may examine the claimant at the Agency's facility in accordance with Office of Personnel Management, (OPM) regulations. However, the claimant's choice of physician must be honored and treatment by the claimant's physician must not be delayed for the purpose of obtaining an Agency-directed medical examination. 

The definition of "physician" includes surgeons, podiatrists, dentists, clinical psychologists, psychiatrists, optometrists and osteopathic practitioners. 

Not considered a physician under the Act are Physician Assistants, RN's, Nurse Practitioners and Physical Therapists. Medical evidence by these providers will not be given any weight by OWCP as they are not considered physicians under the Act.

The services of Chiropractors may be reimbursed, but ONLY for treatment consisting of manual manipulation of the spine to correct a Subluxation. An X-Ray must demonstrate the Subluxation. The Chiropractor cannot read the X-Ray and provide the results to OWCP, OWCP requires that X-Rays taken by a Chiropractor be read by an individual trained in the reading of X-Rays.

Physicians whose licenses to practice medicine have been suspended or revoked by a State licensing or regulatory authority will not be recognized as 'Qualified Physicians' by OWCP. 

This information is also true for OWCP's physicians, so claimants should always check to see if the OWCP-directed physician has a valid license. You can do this by going to the Licensing Board of your State. 

The above information can be found in the Federal Employee's Compensation Act, (FECA) Manual part three at 3-0300 as well as the CA-810. The link to part three of the FECA Manual and the CA-810 can be found on the "Links" tab above.

This information is also covered under the Code of Federal Regulations, (C.F.R.) at 20 C.F.R. 10.316. I'm including the language below:

20 C.F.R 10.316: 
After selecting a treating physician, may an employee choose to be treated by another physician instead

(a) When the physician originally selected to provide treatment for a work-related injury refers the employee to a specialist for further medical care, the employee need not consult OWCP for approval. In all other instances, however, the employee must submit a written request to OWCP with his or her reasons for desiring a change of physician.

(b) OWCP will approve the request if it determines that the reasons submitted are sufficient. Requests that are often approved include those for transfer of care from a general practitioner to a physician who specializes in treating conditions like the work-related one, or the need for a new physician when an employee has moved. The employer may not authorize a change of physicians.

No comments:

Post a Comment