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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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).
- 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.
- 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
- 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.
- 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.
Disposition: This Bulletin is to be retained until incorporated into the Procedure Manual.
ANTONIO RIOS
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.
| FECA BULLETIN NO. 18-04 Issue Date: June 15, 2018 |
You can find the text of the rule here:
https://www.dol.gov/owcp/dfec/regs/compliance/DFECfolio/FECABulletins/FY2016-2020.htm#FECAB1804
