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Thursday, June 21, 2018

OWCP fax numbers

I am frequently surprised that claimants are unaware that they can fax documents to their OWCP office. The contact information for each district office, including the official fax number, is found on the web at this link:

If you have a new injury, it is critical that your claims examiner receive all of the records being generated by your doctors. Be sure to mark your claim number on each pieces of paper and fax, mail, or upload that to your file. Do not rely on other people. If you want your claim to get approved, YOU should gather all records and send them to OWCP. Mailing to the PO Box in London Kentucky can be very slow, you should either upload documents using ECOMP or fax things. Anything that you mail or fax MUST have your OWCP claim number clearly marked on the top right. During the time that your claim is pending approval, you need to be on top of this. Once the claim is approved, the doctors will send in the paperwork when they send in bills. But prior to the approval, you need to make sure that everything is getting in the file by taking care of it yourself.

If the claims examiner ends up with two copies, so what, if they do not get something critical, your claim could get denied.

Monday, June 18, 2018

OWCP Publishes New Opioid Prescribing Guidelines for FECA cases

The Federal Employee Compensation program has been slowly dealing with the opioid crisis and has published guidance on changes to the program regarding opioids. The new guidance is in the form of a FECA Bulletin which provides:

Subject: Opioid Prescribing Guidelines, Short-Term, Long-Term and High Dose Opioid Use
Background: Under the Federal Employees' Compensation Act (FECA), the Department of Labor's (DOL) Office of Workers' Compensation Programs (OWCP) may provide to an employee injured while in the performance of duty, the services, appliances, and supplies prescribed or recommended by a qualified physician, which OWCP considers "likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of the monthly compensation." See 5 U.S.C. 8103.
In accordance with the discretion granted to DOL and delegated to OWCP, OWCP's Division of Federal Employees' Compensation (DFEC) implemented a policy applicable to newly prescribed opioid users (i.e. where an opioid has not been prescribed within the past 180 days, if ever) in FECA Bulletin 17-07, issued on June 6, 2017
DFEC is now instituting a new supplemental policy to address long-term and high dose opioid therapy. While FECA Bulletin 17-07 applies to newly prescribed opioid users, and requires their treating physician to complete a Certification/Letter of Medical Necessity, Form CA-27 (LMN), after an initial 60-day period, this policy focuses on the effects of opioid therapy for all users. For long-term and/or high dose users where the prescribed opioid therapy is deemed to require further management, completion of Form CA-27 will now be required upon DFEC's request1. Claims staff will review factors such as the claimant's morphine-equivalent dose (MED), recent surgeries and the cumulative, continuous length of treatment in assessing the most appropriate action to take in each particular case.
In order to effectively and efficiently manage opioid prescriptions, DFEC has created Prescription Management units within DFEC's Branch of Program Integrity, Fraud Prevention and Prescription Management. DFEC currently has four Prescription Management Units located throughout the country (Jacksonville, Seattle, New Orleans and Chicago), and these units are staffed with Medical Benefits Claims Examiners (MBE). The MBEs are assigned cases based on claimant information (as opposed to OWCP case file number), so an MBE will be assigned cases throughout the country, rather than based on geographic jurisdictional lines (traditional district office assignments).
This means that DFEC has two types of claims examiners involved in medical case management. MBEs are responsible for reviewing and evaluating entitlement to compounded drug and opioid prescription medications and any related requests. They are also involved in ancillary duties that may arise during such medical case evaluation, to include claim expansion (inclusion of new, additional conditions based on medical evidence; approval and denial of treatment regimens; and/or issuance of decisions regarding entitlement to medical care).
Responsible Claims Examiners (RCE), located within each District Office, will continue to serve as the primary point of contact for the claimant for handling all other aspects of the case, to include initial and recurrence adjudications, payment of compensation, periodic entitlement reviews, job offers (temporary and permanent), loss of wage earning capacity determinations and disability management.
Purpose: To provide supplemental guidance to MBEs and RCEs on the management of cases and the authorization of opioid prescriptions where a claimant is receiving opioids for a work-related condition (other than cancer).
Action: For opioid prescriptions for any work-related condition other than cancer:2
  1. Upon review of an opioid recipient's MED and/or length of opioid treatment, the MBE may determine that further medical development is necessary. If so, the MBE should issue a letter to the attending physician. The letter should (1) address opioid-specific issues, (2) address other medical case management/entitlement issues, if applicable, and (3) request that the physician complete the LMN for consideration of further opioid authorization. The MBE should afford a reasonable period of time (generally 30 days unless there is an urgent concern for safety/health in which case 14 days' notice will suffice) for the submission of such documentation, depending on the nature of the inquiry.
  2. Following the expiration of the afforded time to respond, the MBE should review the medical evidence of record, to include the justification provided on the LMN and/or the supporting medical documentation. In evaluating whether further development is necessary, the MBE should assess factors including, but not limited to, (1) whether the physician has demonstrated enough knowledge regarding the claimant's medical condition to arrive at a sound medical opinion, (2) the level of medical rationale provided by the physician, and (3) whether the necessity is based upon objective clinical findings versus subjective complaints. See FECA Procedure Manual 2-810.6 for additional discussion on weighing and evaluating medical evidence.
  3. Should the MBE determine additional development is needed, he or she may again contact the claimant's physician for clarification. Depending on the sufficiency of the file describing the medical necessity for opioid usage, the District Medical Advisor (DMA) may also be consulted to determine the appropriateness of the opioid prescription and pain management plan, including requests for treatment/rehabilitation plans to treat dependence on opioids resulting from prescriptions for an employment-related condition. See FECA Procedure Manual 3-900.4 regarding the handling of concerns about medical treatment. The MBE may also choose to send the claimant for a second opinion (SECOP) examination if warranted based on the evidence of record. If a Field Nurse (FN) has been assigned to the case, the MBE may also direct the FN to address the issue of ongoing opioid usage with the treating physician. If a FN is not currently assigned, the MBE may make a task-based nurse referral to assist with opioid prescription management issues.
  4. If a conflict in medical opinion arises between the claimant's attending physician and either a SECOP examiner or DMA, the MBE should refer the claimant for a referee medical examination (RME) to resolve the conflict.

  5. Following appropriate development, if the medical evidence establishes that the opioid treatment is warranted, the MBE should notate the case record and review the case again at a reasonable interval.
  6. Following appropriate development, if the medical evidence establishes that the current opioid treatment is not warranted for the work-related condition(s), the MBE should review the medical evidence to determine whether any physician that has reviewed the case opines that the claimant would benefit from medication assisted treatment (MAT) or other treatment for opioid use disorder. If no such evidence exists, the MBE should proceed with the issuance of a proposed termination of entitlement to opioid medications. A period of 30 days should be provided for a response. After 30 days, the MBE should again review the case and any response, and either issue a final termination denying opioid entitlement or take additional development action as needed.
  7. If one of the physicians evaluating the claimant states that he or she would benefit from MAT or other treatment for opioid use disorder, the MBE should advise the claimant and the attending physician of such recommendation. If the attending physician disagrees or fails to respond, the MBE may explore (along with the claimant) information about appropriate treatment centers and may authorize a change of physician if the claimant wishes to seek treatment with another physician. If the claimant and attending physician support an alternative treatment plan, the MBE should authorize treatment and monitor progress as appropriate. A task-based nurse may be assigned to assist in facilitating this process. If the claimant and/or treating physician are ultimately unresponsive and/or not interested in pursuing any change in treatment plan, the MBE should proceed with the issuance of a proposed termination of entitlement to opioid medications (if the weight of the medical evidence continues to establish that the current opioid treatment is not warranted).

  8. In some instances, the weight of the medical evidence may establish that entitlement to opioid medication should be reduced instead of terminated. In such cases, the MBE should advise the claimant and attending physician of the availability of MAT or other treatment for opioid use disorder if recommended by a physician. The MBE should subsequently follow the guidance provided in item 6 or 7 above, except that a proposed reduction of opioid medication should be issued.
  9. A period of 30 days should be provided for a response to any proposed termination of, or reduction in, opioid medication. Following that period, the MBE should again review the case and any response, and either issue a final termination denying opioid entitlement or take additional development action as needed.3
  10. In addition to addressing the opioid issue, the MBE may also address other aspects of the claimant's medical condition that may have impact on the management of the case. The MBE will be able to take actions necessary to resolve the opioid issue and to address necessity of medical treatment, including issuing letters to accept additional medical conditions, issuing decisions to deny entitlement to medical treatment, and proposed terminations of medical and/or benefits. In such cases, the MBE should communicate with the RCE concerning actions that may impact the overall management of the claim. These communications may be documented through a CA-110 or memo to the file.
  11. Only the RCE will be responsible for taking actions involving disability or schedule award compensation. In addition, the RCE will still be responsible for periodic entitlement reviews, disability management and vocational rehabilitation efforts. The RCE will also issue decisions regarding termination of entitlement to benefits, even if the determination is based upon medical evidence received as a result of the MBE's actions or if the proposed termination was issued by the MBE. Additionally, in cases where a claimant may have entitlement to compensation as a result of an action taken by the MBE (i.e., stopping work for an in-patient treatment, etc.) the RCE will be responsible for making the compensation payments.
Applicability: Appropriate National and District Office personnel.
Disposition: This Bulletin is to be retained until incorporated into the Procedure Manual.

Director for
Federal Employees' Compensation
Distribution: All DFEC Staff
1 The issuance of this bulletin does not supersede or otherwise modify existing guidance on opioid prescribing guidelines provided in FECA Bulletin No. 17-07 (issued June 6, 2017).
2 The issuance of this Bulletin does not supersede or otherwise modify existing guidance on Fentanyl. See FECA Bulletin No. 11-05 (issued May 3, 2011).
3 If the proposed termination addresses issues other than opioid medication (i.e. termination of all medical benefits), the final termination should be issued by the RCE and not the MBE. See items 10 and 11. Also note that a termination of entitlement to opioid medication alone does not terminate entitlement to MAT or other treatment for opioid use disorder.
Issue Date: June 15, 2018

You can find the text of the rule here: