Friday, April 4, 2014
Revisions to the FECA Manual 3-0500 regarding Independent Medical Examinations, (IME)
An Independent Medical Examination, (IME) also called a Referee examination is scheduled to resolve a medical conflict between the claimant’s physician and OWCP’s physician.
OWCP assigns more weight to the opinions contained in an IME report and negative decisions are often issued from these opinions. This is why the IME physician must be chosen at random on a rotational basis.
Once OWCP selects the IME physician for a claimant, a report called the ME023 is generated.
The Employees’ Compensation Appeals Board, (ECAB) has questioned OWCP’s documentation of the process of selecting the IME at random; stating that OWCP has other documentation available that was not being presented by OWCP as evidence of the rotational selection and that the ME023 report alone was insufficient to substantiate proper random selection of the IME physician.
Due to the questions and concerns from the ECAB, the requirements of documenting an IME have been revised and the ME023 report has been enhanced.
The enhancements include a listing of all physicians contacted and bypassed prior to the selection of the IME physician, as well as a certification statement. This information was previously included in certain case files via screen shots, but in many cases that information was not readable due to the quality of the screen shots and in turn unusable by the claimant in proving whether or not the IME was in fact selected on a random rotational basis.
The updated version of the ME023 report can only be generated for IME appointments created on and after December 17, 2012. It cannot be generated for appointments made prior to December 17, 2012.
The process for IME selection and scheduling has not changed. OWCP will continue to use a rotational method for selection of IME physicians but the prior version of the ME023 report (without bypass information) can no longer be duplicated.
Under the new system, when the scheduler inputs the appointment date and time, the ME023 is generated for imaging directly into the claimant’s case file.
A 200 mile radius has been set as the outer limit for zip code selection. The FECA Manual part three has been updated to indicate that this 200 mile radius is calculated from the claimant’s home zip code.
Updates were made to the IME selection process so that the physicians were automatically grouped into zip clusters based upon specified mileage ranges outside of the initial zip cluster (50 miles, 75 miles, and continuing in 25 mile increments up to 200 miles), now seen on the ME023 report.
Where circumstances exist (such as when an obscure specialty is required, or no physicians of the required specialty are within the 200 mile radius), scheduling outside the 200 mile range may take place. If this occurs, the scheduler should consult an appropriate directory of medical specialists to obtain names of suitable physicians for referral.
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. Documentation outlining the rationale for this decision must now be placed in the case file, and the decision must be approved by a Supervisory Claims Examiner or higher level authority.
If all physicians presented are bypassed and there are no physicians available within the 200 mile zip code range, the application system 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.
When the scheduler inputs the claim number, the claimant’s home zip code is automatically loaded. The scheduler then selects the specialty of the physician required. Based on specialty and zip code, the next physician on the roster appears on the screen. This continues until the appointment is scheduled.
The roster of physicians is not visible to the scheduler and s/he can only see and update information pertaining to the selected physician until a decision is made to schedule the IME or bypass the physician. The search results are in alphabetical order, based on the specialty and the claimant’s home zip code. As physicians are bypassed and/or already have appointments scheduled, the physician is then placed at the bottom of the roster.
The scheduler will then contact the physician and determine if the appointment can be scheduled in a timely manner.
If the appointment cannot be made in a timely manner, the scheduler updates the application with an appropriate bypass code. Once a bypass code is entered, the system will then present the next physician on the roster. This continues until the IME is scheduled.
If the appointment can be scheduled, the scheduler inputs the appointment date and time onto the application. The ME023 report is then copied into the claimant’s file and the claimant is notified of the IME appointment.
The ME023 report can only be generated through this application process and serves as the claimant’s evidence that the IME was scheduled on a rotational basis. If for some reason the ME023 report is not included in the claimant’s file at the time the IME is scheduled a copy of the ME023 can be obtained by OWCP. However, under the new system, no adjustments can be made to the original information contained within the ME023 report and it will have the original date the report was generated.
If a scheduled IME has to be cancelled or rescheduled for any reason, the claimant’s file should be clearly documented using the appropriate code.
Codes used during the IME scheduling process are as follows:
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.
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.
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 OWCP patients. This code is used if the physician will not accept any OWCP cases, will not do an IME, will not accept workers’ compensation cases, or is not willing to perform examinations for OWCP.
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 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 the 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 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 the database. The medical scheduler should attempt to obtain current contact information to update the physician’s address. If the physician is still within the same zip codes as the address in the 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 scheduler must leave a message. If a message must be left, the 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.
Code S – Sub-specialty. 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 extremity injury.
Code U - Physician in use by another scheduler. This code is used when the physician is in use by another scheduler. It is not available as a bypass option; it is automatically updated when the next physician in the rotation is currently in use or in pending status (being contacted for an appointment) by another scheduler.
If a claimant is being sent to or has been sent to an IME on or after December 17, 2012, a copy of the ME023 report and all other documentation should be requested so that the claimant has proof the IME was in fact randomly selected. If the IME appointment is outside the 200 mile range of the claimant’s zip code, documentation must now be in the claimant’s file.
If the claimant hasn’t done so, a copy of the claimant’s file should also be requested as the ME023 report and all other documentation should be contained in the claimant’s file and often it is quicker for a claimant to get a copy of their file than a response from their CE.
If the IME was not randomly selected, the claimant can use that information to overturn the IME report or use the fact that the IME was not randomly selected on appeal.