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Thursday, September 18, 2014

How do I find a physician willing to bill OWCP for treating me?

Unfortunately, because the federal employees compensation act process makes OWCP's claims actions unreviewable by any court, those running OWCP have created a system that is designed completely for their own convenience, not the convenience of the injured worker. Some years ago, OWCP began to require that medical providers "enroll" in the OWCP system so that they can get a "provider number" from OWCP. Without a provider number, physicians cannot bill OWCP for treating you. Medical providers already need to enroll with and get a number from Medicare. Why OWCP could not use that existing system, and supplement it with their own system for the obscure situation where a provider does not have a medicare number only makes sense if you recall that OWCP is only concerned about making this process convenient for OWCP. The practical effect is that many injured workers have a great deal of trouble finding a medical provider willing to treat them. If you are having difficulty finding someone to treat you, OWCP does have a tool that allows you to search their database for physicians who have provider numbers. If you click on the link below, and click on the "accept" button, then you select that you want to search in the "FECA" program. you can then do a search:

The search function is fairly straightforward. One limitation is that certain specialties are not broken out. For instance, under specialties, they do not allow you to limit your search to "psychiatrist" or "psychologist". Therefore, to find a specialist who is not categorized, you need to first do a search in the geographic region you are looking in, then, for any physician who does not have a specialty listed, you can google that doctor's name and see whether that doctor is the type of specialist you are looking for.

If you are unable to locate a provider in your region willing to bill OWCP for treating you, you should document that you went through the list and bring this to the attention of your congressman and request a congressional inquiry. This problem is routinely brought to the attention of those running OWCP, they do not seem to be concerned. The only way they will fix this situation is if they receive scrutiny. If a congressman were to conduct hearings on this issue and ask the director of the program to explain why they are unconcerned with this situation, it might get fixed.

Tuesday, September 9, 2014

OWCP and travel reimbursements

Many OWCP claimants have great difficulty with getting their travel reimbursements processed correctly. In particular, OWCP makes this process particularly onerous on injured workers who are seeking specialized medical care that is not available in their own community as OWCP routinely refuses to reimburse for travel beyond fifty miles each way unless there are unique circumstances. Unique circumstances include that you live in a remote location and the care you need is not available locally or you have an unusual medical condition that cannot be treated locally. You will likely need a letter from a local doctor explaining why you need to travel more than 50 miles to get the type of care you need.

The people writing these rules live in Washington, DC, a region spilling over with specialized medical care. While most claimants live in areas with far fewer doctors. Always keep in mind that OWCP's rules are written from OWCP's perspective, the design and operation of this program is to make things as convenient for those running this process, not for the needs of the injured workers.

Following is a recent document that discusses this process:

Issue Date: January 29, 2014

Subject: Reimbursement of Travel Expenses for Claimants and Providers Providing Transportation Services
5 U.S.C. §8103 of the Federal Employees' Compensation Act (FECA) provides that an injured employee is entitled to receive medical services, appliances or supplies which a qualified physician prescribes or recommends and which OWCP considers necessary to treat the work-related injury. This section further provides that an employee may be furnished necessary and reasonable transportation and expenses incident to the securing of such services, appliances and supplies when authorized. See 5 U.S.C. 8103. This circular briefly describes the circumstances and limitations on authorizing and paying for transportation services.
Effective August 29, 2011, 20 CFR §10.315, provides in pertinent part as follows with regard to payment for transportation to obtain medical treatment:
(a) The employee is entitled to reimbursement of reasonable and necessary expenses, including transportation needed to obtain authorized medical services, appliances or supplies. To determine what is a reasonable distance to travel, OWCP will consider the availability of services, the employee's condition, and the means of transportation. Generally, a roundtrip distance of up to 100 miles is considered a reasonable distance to travel. Travel should be undertaken by the shortest route, and if practical, by public conveyance. If the medical evidence shows that the employee is unable to use these means of transportation, OWCP may authorize travel by taxi or special conveyance.
(b) For non-emergency medical treatment, if roundtrip travel of more than 100 miles is contemplated, or air transportation or overnight accommodations will be needed, the employee must submit a written request to OWCP for prior authorization with information describing the circumstances and necessity for such travel expenses. OWCP will approve the request if it determines that the travel expenses are reasonable and necessary, and are incident to obtaining authorized medical services, appliances or supplies. Requests for travel expenses that are often approved include those resulting from referrals to a specialist for further medical treatment, and those involving air transportation of an employee who lives in a remote geographical area with limited local medical services.
Background: The change to requiring suspension of the reimbursement request and referring the request for claims examiner review whenever the request involves more than 100 miles per day of mileage reimbursement (Section A below) was effective January 17, 2013. The additional procedures outlined in this Bulletin were effective July 17, 2013.
Purpose: The purpose of this Bulletin is to address the manner in which travel procedure codes will be processed and paid by the Central Bill Processing (CBP) system when submitted for authorized examinations/treatments.
Applicability: Appropriate National Office and District Office personnel and FECA medical billing contractor.
A. Mileage Reimbursement for Examinations/Treatment. Periodically and in certain situations, travel to authorized examinations and/or treatment could exceed the allowable 100 mile distance outlined in 20 CFR 10.315(a) as noted above. When a claimant submits a reimbursement request (on Form OWCP-957, Medical Travel Refund Request) in excess of 100 miles for a single date of service, the bill will be automatically suspended and the CBP provider will send notification to the claims examiner seeking authorization. The notification sent by CBP will include the applicable date(s) of service, as well as the miles being claimed.
1. If the request is for a single trip and the mileage claimed is allowable, such as for a scheduled Second Opinion (SECOP) or Independent Medical Examination (IME), the Claims Examiner (CE) will simply authorize the reimbursement.
2. In limited circumstances it may be necessary for a claimant to travel more than 100 miles on a regular basis, such as to be seen by his/her treating physician or therapist if the claimant lives in a remote area. Upon receipt of notification from CBP in these instances, the CE should provide a range for this ongoing authorization, including both total miles and period that the authorization covers. This range should be calibrated to the claimant's treatment location and can extend up to 900 miles and up to six (6) months in length, using Procedure Code A0080.
3. Should the claimant exceed the miles authorized within this period, the CE will again be notified by CBP. If such travel is medically necessary for the work-related conditions, the CE has the authority to authorize an extension of the mileage, but can only do so after writing a memo to the case file to justify the increased number of miles allowable.
4. If the need for increased mileage continues past the initial six month authorization period, another authorization and memo to the file is also required for an additional 6 month period. Such authorization and documentation is required every 6 months.
5. If the proper authorization is on file, or the requested mileage does not exceed 100 miles for a single date of service, the bill will simply be processed by CBP. There will be no need for a notification to be sent to the CE.
B. Incidental Charges. Periodically, a claimant could incur incidental charges that may exceed $75.00 while travelling to authorized examinations.
1. If the claimant requests reimbursement for any of the following procedure codes (including those that require prior authorization), and the charge exceeds $75.00, the system will post Edit 501 (Service exceeds Allowable amount, Original Receipt/Invoice of the charge is required).
A0110 – Taxi
A0120 – Mini Bus
A0130 – Wheel Chair Van
A0140 – Air Travel
A0170 – Tolls/Parking
A0180 – Lodging
A0190 – Meals
A0200 – Lodging Escort
A0210 – Meals Escort
2. If the receipt/invoice is present, a notification will be sent to the CE to obtain authorization for the amount. However if the receipt/invoice is not present, the service will be denied for Edit 501. CBP will not send a notification to the CE if there are no receipts attached; it will simply deny the charge.
3. If the claimant submits a request for reimbursement of "TRANS," and there is no description present for using this code or the description is equal to "GAS," the system will post Edit 520 (A description of the service is required. Please provide the description and resubmit. Gas is not covered.) and deny the charge since charges for gasoline are not permitted in addition to mileage reimbursement.
Note: Where a claimant has been denied authorization for treatment or reimbursement for expenses related to transportation, a formal decision with appeal rights will be issued upon claimant request. Amounts paid (including amounts paid under the OWCP fee schedule) for medical services are not appealable to ECAB. See 20 C.F.R. § 10.625.]
C. Payment to Transportation Providers. The OWCP-1500 Form is to be used by those providing authorized transportation to claimants for medical treatment/appointments.
1. If the charge for these services exceeds $75.00, prior authorization is required and the bill must be accompanied with an invoice justifying the charge.
2. A provider must have prior authorization for any of the following transportation procedure codes if the charge billed exceeds $75.00:
A0100 - Taxi
A0110 – Bus
A0120 – Mini Bus
A0130 – Wheel Chair Van
A0140 – Air Travel
A0170 – Tolls/Parking
If there is not an authorization on file or the provider fails to submit an invoice, the system will post Edit 501 and deny the bill. In those instances where the amount being billed exceeds the amount authorized, CBP will send a notification to the CE requesting direction to extend the dollar amount of the authorization, to pay only the authorized amount, or deny the service.
3. If the billed charge is less than $75.00, no edit will post and the bill will be processed through the system, even without a receipt or invoice.
4. Providers who bill using mileage codes A0080 and/or A0090 will be paid based on the current GSA mileage rate, and prior authorization is required if the miles/units billed is for more than 100 miles/units for a single date of service. If an authorization is not on file, the CBP will deny the bill.
D. Mileage Reimbursement for Pharmacy Pick up
A claimant may claim mileage for pharmacy pick up to his or her local pharmacy; reimbursement is generally limited to the closest pharmacy by the shortest route.
Disposition: This bulletin is to be retained until the FECA PM has been updated.
Director, Federal Employees' Compensation