OWCP and ICD-10 CM/PCS

The implementations of ICD-10 promises to create havoc and anarchy in the OWCP process as accepted conditions get reinterpreted, likely to the detriment of injured workers. Fortunately, we have a brief reprieve. Due to overwhelming concerns in the medical community as to the effect of this change, President Obama recently sign the SGR Patch bill, HR-4302, which delayed ICD-10 CM/PCS implementations until October 1, 2015.

Although there is a delay in the implementation of ICD-10 CM/PCS, OWCP is still requiring that providers use the revised HCFA 1500 claim form (version 2/12) to report services rendered using the current ICD-9. The implementation of ICD-10 promises to bring additional havoc and confusion to an OWCP process that places tremendous burdens and hurdles on injured workers who frequently have difficulty finding physicians who are willing to accept their cases due to OWCP operating a system that is designed purely for the convenience of those running OWCP with little if any consideration of the needs of injured workers and medical providers. Current versions of OWCP approved forms for FECA cases can be found through their website at the following location:

http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

OWCP and balance billing

Balance billing is a phrase that describes the situation where a medical provider tries to collect the amount that their bill was reduced when OWCP paid the provider's bill based upon the fee schedule. If a doctor charges $200 for an office visit, OWCP pays that bill in the amount of $120, and the provider then tries to collect the "balance" of $80 from you, that is called balance billing. Medical providers who accept payments in FECA cases are prohibited from balance billing and can be debarred for engaging in this practice. A medical provider agrees to accept what OWCP pays for a service and is not allowed to try to collect the balance from you. See 20 CFR 10.813: If OWCP reduces a fee, may a provider bill the claimant for the balance? A provider whose fee for service is partially paid by OWCP as a result of the application of its fee schedule or other tests for reasonableness in accordance with this part shall not request reimbursement from the employee for additional amounts. (a) Where a provider's fee for a particular service or procedure is lower to the general public than as provided by the schedule of maximum allowable charges, the provider shall bill at the lower rate. A fee for a particular service or procedure which is higher than the provider's fee to the general public for that same service or procedure will be considered a charge “substantially in excess of such provider's customary charges” for the purposes of §10.815(d). (b) A provider whose fee for service is partially paid by OWCP as the result of the application of the schedule of maximum allowable charges and who collects or attempts to collect from the employee, either directly or through a collection agent, any amount in excess of the charge allowed by OWCP, and who does not cease such action or make appropriate refund to the employee within 60 days of the date of the decision of OWCP, shall be subject to the exclusion procedures provided by §10.815(h).

Time limitations to submit medical bills and requests for reimbursement of medical bills

OWCP's regulations (5CFR§10.803) provide that a medical bill, medical reimbursement request, or travel voucher must be submitted on an approved form and in a timely manner. Such bills will not be paid for expenses incurred if the bill is submitted more than one year beyond the end of the calendar year in which the expense was incurred or the service or supply was provided, or more than one year beyond the end of the calendar year in which the claim was first accepted as compensable by OWCP, whichever is later. Note that OWCP's bill processing software does not take into account the last portion of the above rule. Therefore, under the circumstances of a claim that was not approved right away, the time for submitting bills is extended to December 31 of the year following the year in which approval of your case or the relevant medical condition occurred. When such bills are routinely denied under these circumstances, you will need to follow up with your OWCP claims examiner and request that a "thread" be sent to the medical bill processor indicating that the bill was not untimely.

Resolution of a third party case may entitle you to be paid additional money by OPM

In a small number of OWCP claims, the cause of the injury is due to the negligence of a third party. You cannot sue your employer and coworkers, but if your injury was caused by an entity outside of the federal government you might have a third party case. When your third party case is resolved, your lawyer will distribute the money that is recovered, including repaying OWCP for some or all of the wage loss payments you have received. When that occurs you are repaying the workers compensation payments that you previously received. If you are also approved for your regular or disability pension, repaying the workers compensation wage loss pay may trigger entitlement to a payment from OPM for that closed period of time that you have had to repay OWCP. This can add up to a significant amount of money. If you have settled a third party case, you may be entitled to a payment from OPM for the period that you repaid OWCP.

Timeliness of claims - statute of limitations - don't rely on your OWCP claims examiner

I have recently had several OWCP clients' workers compensation claims erroneously denied as being untimely. The time for filing a traumatic injury claim is within three years of when you knew or should have known you were injured. There are circumstances where you can get around the time limitation. With regard to an occupational injury or disease, there is also a three year time limitation. However, with an occupational injury or disease, the claim is timely so long as it is filed within three years of when you were last exposed to the work factors contributing to your condition. That means if you are subjected to loud noise on the job, and have known for more than three years that that noise has damaged your hearing, you can file your claim up until it has been more than three years since you were last exposed to noise on the job. This type of claim can still be filed even after three years have passed since you were last exposed under certain circumstances. Its not clear why different claims examiners in different OWCP offices are getting this wrong and erroneously denying claims filed far more than three years after the injured worker was aware of their illness, but well within three years of when they were last exposed to the relevant work factors that contribute to the illness. If your claim is denied for any reason, keep in mind that you are entitled to appeal rights for a reason. The reason is that far too many OWCP claims examiners are poorly trained and unfamiliar with basic principles applicable to this system. Those running OWCP spend far too much time lobbying Congress to strip benefits from this program and far too much time working with employing agencies to come up with strategies to deny injured workers benefits that they are entitled to receive. Instead, those running this program should be focusing on providing competent training and mentoring to claims examiners who all too often are assigned so many cases that they are unable to provide quality work. In the end, its much easier to deny a claim and let someone else figure it out, especially in a work environment that values the volume of work completed and places no value on the quality of work completed.

The Government Shutdown and OWCP benefits

I have been receiving many concerned calls from FECA claimants regarding the status of their OWCP benefits in light of the government shutdown. OWCP is continuing to operate. While district offices are not answering telephones, wage loss payments, medical bills, and many case adjudication actions are all continuing to occur. The Branch of Hearings and Review is not conducting hearings during the shutdown.

OWCP recognizes entitlement to Augmented FECA Compensation Based on Claimant's Same Sex Spouse

OWCP now recognizes that same sex spouses are entitled to receive compensation at the augmented rate. If you are in a same sex marriage, you are entitled to receive augmented compensation pay retroactively back to the date of your marriage so long as you have lived with your spouse during this time period. Send a letter to your claims examiner requesting these benefits. You should include a copy of your marriage certificate and in your letter you need to confirm that you have lived with your spouse from the date of your marriage to the present. You may want to print out the link below and include that with your letter in case your claims examiner is unaware of this rule. As always, every piece of paper you send to OWCP should have your claim number clearly marked on the top right.