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Saturday, June 13, 2009

OWCP Hides The Rules and Takes Away Your Rights

Since the late 90's OWCP has posted the procedure manual and other reference materials explaining how claims are to be adjudicated and otherwise addressing specific policy issues. That was a tremendous improvement over the situation when I first started handling these cases when there was a massive paper procedure manual. Updates would arrive in the form of pages that needed to get replaced in the enormous paper document and you would need to replace pages that had been revised.

Keep in mind that FECA is a unique law in that it creates what is essentially a self insurance process for the federal government. There is no appeal out of this process into any court, it is a closed system. The people setting policy are the same people responsible for overseeing the claims process. The statute contains a section, called a "door-closing provision", that bars you from appealing this process into any court. Federal courts consider this system to be "non-adversarial" and there is a long tradition of rules that were designed to protect the injured workers. OWCP has an obligation to help you with your case. This is not like a normal litigation system where each side is simply protecting itself and wins by beating you out of benefits.

Unfortunately, the powers that be at OWCP no longer understand their obligation to the injured worker. Today, this is a system that views injured workers as whining frauds who get in the way of demonstrating to Congress that costs have been reduced and interferes with OWCP management's ability to keep the employing agencies happy.

This shift seemed to reach a tipping point about 5 - 6 years ago. It was at that point that the people running the fed comp process at OWCP decided to get rid of the old way of doing things where they put all the rules applicable to these cases out there for anyone to find and understand. Obviously, they could not do this in an open and honest way, they had to do this by stealth in a way that would not seem obvious.

One of the first things they did was to take down the easily searchable versions of the procedure manual and other policy documents, and replace them with non-searchable gigantic pdf files. Instead of being able to do a text search for a term, now you need to read through pdf documents, some of which can be a thousand pages long, just to find references to a term.

In the same vein, OWCP also simply stopped updating the procedure manual. If you look at the table of contents you can see from the dates that sections were last updated that the procedure manual seems to have been abandoned. It is the same with FECA Bulletins, Memos, and Circulars. They no longer put any substantive rules out there for you to find.

How can this be? There used to be dozens of updates and policy memos every year. There used to be a quarterly summary of significant ECAB decisions alerting examiners to new issues and to recurring errors. In 1999 and 2000 there were two substantial policy documents discussing steps the district offices must take to make the directed medical selection process more fair.

Now, instead of updating the published rules and issuing policy statements explaining how the program is supposed to run, they now do the updates by way of telephone conference calls and internal emails, that they refuse to release in response to FOIA and PA requests, to district directors addressing updates to the program. It used to be that when they released these documents listing the rules, you could then point out that a claim was not being adjudicated in accordance with the published rules. What an inconvience, OWCP being held to a set of rules rather than just deciding cases on an ad hoc basis. Horror of horrors, decisions overturned and deserving claimants awarded benefits that had been denied. We can't have that anymore.

All of this secretiveness seems to be part of the world view shift that happened at OWCP earlier this decade.

The federal comp process has lost its way. Its horribly obvious that the people running this program would abolish the program if they could get away with it. Instead, they are eviscerating it. To these folks, their "customer" is the employing agency. The injured worker is just an inconvenient whiner getting in the way of servicing the employing agency.

Why doesn't the procedure manual get updated any more? Seemingly, this allows OWCP to hide its actions from scrutiny.

The shift away from openness has also come with an increasingly hostile approach at ECAB, the only review of cases that is not completely under the thumb of OWCP. Clearly, ECAB is also now comprised of persons who view the protection of employing agency whims as far outweighing concern for protecting injured workers. ECAB has steadily eliminated rules that once protected injured workers from unfair decisions. This process culminated in the waning months of 2008 with the issuance of a new rule cutting in half to six months, the time one has to appeal a decision to ECAB.

Typical of the disingenuous manner in which ECAB has conducted itself they issued a statement explaining that they were actually increasing the time for an appeal from three months to six months. While technically, the old rule said you had 90 days to appeal, but for good cause you could appeal for a year. In practice, they have always accepted all appeals for one year. Now the rule is six months, and they can waive that under special circumstances and extend it to a year. Clearly, all but the most extraordinary circumstances will result in an appeal after 6 months being denied.

When ECAB described the rule change, they explained that the old rule only allowed an appeal for 90 days, and they had doubled that to 180. They neglected to mention that the old 90 day rule was NEVER interpreted as 90 days, that ALL appeals were accepted automatically for one year. Now you only have six months.


So if you can't find information to help you understand your situation, don't be surprised. OWCP seems to want it that way.

Wednesday, May 20, 2009

New OWCP Tactic

I have noticed a sneaky, new tactic being used by claims examiners to get rid of unwanted medical reports. It is based on a long-standing rule that when OWCP sends you to a directed medical examination (i.e., a second opinion or referee exam), and that doctor does not provide an adequate medical report, then OWCP is supposed to request an addendum from the doctor. If the doctor still does not give a good enough explanation, then that doctor's report is set aside and OWCP must send you to a new doctor. 

What seems to be happening with increasing frequency is that this rule is being used as a pretext for getting rid of doctors' reports that do not fit with the claims examiner's view of a case.

I have had several clients over the last few months who were sent out for directed exams. The doctors wrote reports that were no better or worse than other reports they'd written in dozens of other cases. EXCEPT this time their reports supported the injured workers' cases. The claims examiners proceeded to invent reasons why the reports were not good enough, requested clarifications, and then declared that the clarifications were not good enough either. In this way, they were able to send the claimants to new doctors hoping to get an opinion they liked.

This tactic also sends a message to physicians that if they want more patients sent to them for evaluation and reports, they better say what they think OWCP wants them to say!

Be on guard and don't let yourself fall victim to this new trick! 

Wednesday, April 1, 2009

Beware of Biased Claims Examiners

FECA is considered a “non adversarial” system. Therefore, you would expect the program administrators to be helpful rather than hostile to the injured workers they are obligated to protect. My experience has been just the opposite. Here are some examples:
  • I have one client who was serving in a civilian capacity at a military base high in the mountains of Afghanistan when he suffered a fall and ended up needing a hernia repair, hip replacement, and knee surgery. It is almost four years later, and the claim was again denied by the same claims examiner for the third time. Hearings and Review keeps remanding the case, telling the examiner that he has adjudicated the case in error. The examiner then sits on the case for nine months to a year, and denies it again disregarding the remand instructions.
  • Some time ago, a claims examiner in the Philadelphia district office told me that all of my clients are liars, and the only reason they need to have a lawyer is because they are dishonest. This same examiner telephones injured workers and uses various scare tactics to make them think their cases will go badly because they have a lawyer representing them. Telling them the only reason they need a lawyer is because they are frauds. Workers that rebuff his threats have received unfavorable decisions and written accusations of fraud. When these wrongful actions are brought to the attention of the Philadelphia district office and the National office, the decisions are vacated, but this examiner continues his job without recrimination. He recently sent one of my clients (a decorated and disabled veteran) a letter terminating his benefits for allegedly committing fraud, without any basis for doing so. That decision was quickly vacated by his superiors who blandly dismissed the entire episode as a routine error. This is a system that is run by people who think are obsessed with outsourcing to the private sector, think that workers are frauds, and view this entire process as one that ought to be abolished.
Thankfully, not all claims examiners act or feel this way. But always be on your guard. You may find that the person whose job is to help you is actually completely insensitive to your plight as an injured worker.

Tuesday, March 24, 2009

No COLA for FECA Claimants

In FECA Bulletin 09-02, OWCP explained that federal employees receiving federal workers compensation benefits will not be receiving a COLA this year:

The cost of living adjustments granted to a compensation recipient under the FECA are
based on the “Consumer Price Index for Urban Wage Earners and Clerical Workers” (CPI-W) figures published by the Bureau of Labor Statistics (BLS). The annual cost of living increase is calculated by comparing the base month from the prior year to the base month of the current year, with the percentage of increase adjusted to the nearest one-tenth of 1 percent, determining the amount of the CPI increase granted to claimants. 5 U.S.C. §
8146a establishes the base month as December.

December 2007 had a CPI-W level of 205.777 per BLS. The CPI-W level for December 2008 was reported as 204.813 by BLS, which is in fact a decrease of 0.5% from the December 2007 level. As a result of this decline in the CPI-W level, there will not be a cost of living increase for FECA recipients in 2009.

At the same time, SSA gave Social Security recipients a 5.8% increase. While OWCP personnel have their explanation as to why they gave no increase, you can see the disparity between how a politically powerful group (SSA benefit recipients) versus recipients of benefits from a program that does not care about the welfare of recipients are treated.

Friday, February 13, 2009

Rep. Hilda Solis for Secretary of Labor

The nomination of Rep. Hilda Solis (D-CA) for Secretary of Labor seems to have bogged down. I urge anyone concerned about workers rights to call and write their Senators and Representative urging them to see to it that she is confirmed. You can call the US Senate switchboard at 202-224-2131.

Wednesday, December 10, 2008

OPM Tells Agencies to Accept Late Open Season Enrollments

Federal employees should take note. Your enrollment deadline for health benefits may have been extended this year, and you should pay special attention to the options available to you. The following excerpt is taken directly from www.federaldaily.com:

"In response to widespread concerns over benefit changes that would have required many Federal Employees Health Benefits Program (FEHBP) subscribers to pay a new $7,500 co-payment for out-of-network non-emergency surgeries, the Office of Personnel Management has asked FEHBP carriers to reevaluate those benefits—and has instructed federal agencies to accept belated enrollments for the 2009 open season. The new co-payment in question would have affected enrollees in the FEHBP Blue Cross/Blue Shield (BC/BS) Standard Option. OPM told insurance carriers to propose changes no later than Dec. 8. OPM also said it would not allow changes to premiums or to other types of benefits in 2009. The extension and request for changes comes in the wake of a Dec. 3 hearing on the matter by the House Subcommittee on the Federal Workforce. At that hearing, Dr. Peter Petrucci, president of the medical staff at Sibley Memorial Hospital in Washington, D.C., noted that the new BC/BS policy would make it “financially prohibitive for the majority of patients to obtain surgery and many commonly performed procedures from the doctor of their choice,” and instead force them to obtain those services from providers who had contractual agreements with insurers. BlueCross/Blue Shield insures more than half of federal employees and retirees. To see more, go to: www.opm.gov/news/opm-to-provide-additional-protections-in-2009-for-fehb-enrollees-who-use-outofnetwork-surgeons,1443.aspx."

You can subscribe to a daily email from www.federaldaily.com regarding issues of importance to federal employees.

Wednesday, December 3, 2008

OWCP Demands Reports, But Won't Pay Much If You Can Even Figure Out How To Bill

In an OWCP claim, it really all comes down to medical reports. Medical reports explain how your medical problem was caused by your job. And medical reports document, on an ongoing basis, how your injury or condition continues to limit your ability to work. Accurate, thorough and timely medical reports are the cornerstone of a successful OWCP claim.

That is why OWCP’s unfair and one-sided handling of medical reporting is so egregious. Here’s how it works:

Once your claim is approved, OWCP requires periodic medical reports from your doctor. These reports are to be written in the form of a narrative, discussing how you were hurt, what has transpired from then until now, and how your condition or need for treatment relates to that injury. This can be a complicated and time-consuming report for your doctor to prepare. But, here's just one of the many places that OWCP plays “gotcha.” Their letter will tell you that your doctor should bill them for this medical report, but they don’t provide explicit billing instructions. If you ask for clarification, they will tell you that the doctors' offices are supposed to know how to bill for what they do. (Guess what, they often don’t know how to bill OWCP.)

The billing code for this sort of a medical report is 99455 (for your treating doctor) and 99456 (if it is any other doctor). But, be advised that this code can only be used once a year on a case, and the doctor cannot bill for units of time, just the code. Your doctor will then get paid a set amount that is far below what OWCP pays their selected second-opinion and referee examiners. And what happens if you have two doctors--an orthopedic surgeon and a psychiatrist? What happens when your claims examiner asks for another report or wants to ask follow up questions from your doctor? What happens if you have a new or additional doctor who needs to spend a significant amount of time reviewing your records in order to prepare a report? According to OWCP, that's your problem; they are not going to pay for this.

Whereas your doctor will only get paid for one report per year, OWCP will frequently send you to multiple doctors and get multiple “clarification reports” in any one year. You better believe their doctors are paid for each and every report, and they are paid the going rate for their services.