The Role of Medical Opinions in Managing Federal Workers Compensation

The federal workers’ compensation system, administered by the Department of Labor’s Office of Workers’ Compensation Programs (OWCP), works differently than state workers’ compensation systems but still offers many opportunities for obtaining medical opinions. Here is a brief primer on the rules related to obtaining medical opinions.

OWCP relies on the treating provider of record to provide sufficient detail and rationale to enable their Claims Examiners to make claims adjudication and treatment authorization decisions. The employing agency has a right to review these notes. Exercising that right is easier if the employer routinely asks injured employees to sign an authorization for release of medical information related to the claim.

A common mistake made by treating providers unfamiliar with the federal system is to state an intent to refer to a specialist in a treatment note, and hope that this will suffice to “make it so.” Unlike many state systems, in which a case manager will note this request and act on it, such automatic review and action is not part of the federal system. Support staff at the treating provider’s office should arrange referrals and may receive assistance from agency representatives.

The approved treating provider may refer the patient to any specialist for consultation or care, without obtaining OWCP pre-authorization. An injured worker wishing to see a specialist should request this of the treating provider. As long as the specialist is a local enrolled provider, uses the diagnosis codes for the accepted condition(s) in billing and submits bills properly, payment should not be a problem.

In state workers’ compensation, the employer or insurer can usually obtain a second opinion exam from an appropriate specialist. The federal employer does not have this option. Although the employing agency may request a second opinion examination from OWCP, there is no guarantee they will grant the request. If the claimant is still on the federal agency employment rolls, the employer may refer the claimant for an Agency Medical Exam, according to Office of Personnel Management (OPM) guidelines (5 CFR 339). The Agency Medical Exam will not usually be given the same weight by the OWCP Claims Examiner as the treating provider’s opinion, but it may trigger OWCP actions such as an OWCP arranged second opinion exam. There are strict rules about setting up Agency Medical Exams.

4. Ask for Clinical Claim Reviews
Federal agencies with access to in-house or contract Occupational Medicine physicians and/or nurse case managers should utilize their services to review medical documentation provided in relation to workers’ compensation claims. Reviews by clinicians can provide you with needed information and medical analysis related to causation, prognosis and return to work planning. Critical review of the medical documentation provided in relation to the claim can be used to determine whether continuation of pay should be controverted, and are useful when an agency is deciding whether to challenge a claim based on the medical facts.

Written reviews by clinicians are also helpful in obtaining needed decisions from OWCP, including treatment authorization or referral for second opinion exams. Agency clinician correspondence with the treating provider can be invaluable in obtaining clarification of opinions, enhancing progression toward recovery, triggering decisions about maximum medical improvement, and soliciting cooperation in return to work planning.

The OWCP Claims Examiner may decide that a second opinion examination is needed in order to obtain additional information about a claim, when the documentation coming from the treating provider is not clear or contains discrepancies. Such an exam is usually performed by an appropriate specialist, via a network contracted with DOL. These exams usually require the Claims Examiner to prepare a Statement of Accepted Facts (SOAF) for the examining physician. These exams are most often performed to determine whether surgery is needed, whether an accepted condition has resolved or reached the point of maximum medical improvement, or the degree of disability. Federal agencies should monitor the medical progress and documentation closely, and if questions arise, request a second opinion from the Claims Examiner.

It is important to make a clear and concise justification for this action, and follow up the response. Once the second opinion exam is done, ask for a copy of the report. Clarify with the Claims Examiner the status and plans related to follow-up actions indicated by the second opinion, such as additional testing, other specialty evaluations, or obtaining a review and response from the treating provider. It is important to find out what the Claims Examiner is planning to do if the second opinion is in conflict with the treating provider’s opinion or treatment plan. The Claims Examiner may decide to obtain a “referee” exam (or IME). A referee exam is performed by an appropriate specialist who is usually under contract with the given DOL district office. Make sure you ask for the referee report, since it will often provide the basis for a return to work offer or necessary administrative decisions. (workersxzcompxzkit)

Although the treating provider of record is the primary source of clinical information needed by the Claims Examiner, there are other options available to federal agencies to obtain additional clinical perspective and opinions.

Guest Author: Marianne Cloeren, MD, MPH, FACOEM is medical director of Managed Care Advisors, Inc. (MCA). Since 1997, MCA has successfully designed, implemented, and managed employee health and welfare and workers’ compensation programs for large public and private corporations, and local, state and federal government entities. Our team of consultants and clinical professionals are in the business of maximizing health and productivity. Contact Dr. Cloeren at 301-469-1660; mcloeren@managedcareadvisors.com; www.managedcareadvisors.com.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.