OWCP CASE MANAGEMENT

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• OWCP CASE MANAGEMENT
• KATE CRAMER
• OWCP PROGRAM MANAGER
• VA MEDICAL CENTER
• BAY PINES, FLORIDA 33744
• [phone]

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CONTROVERSION OF COP
C O P

• DISPUTE OF CLAIMS

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• We recognize that the majority of claims are
  legitimate and we believe those claimants should
  be helped in any way possible to improve their
  health and resume a full and productive life.
• The EEO Commission has noted an agencys
  obligation to controvert an employees OWCP claim
  where there is a dispute as to the stated facts.
• The law states that to receive benefits under
  the FECA there must be a claim (CA-1) Therefore,
  if you do not have a signed CA-1 you cannot
  authorize medical care or COP.

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KEYS TO SUCCESS

• Occupational Health Physician
• Well Trained Supervisors
• Know FECA Regulations - Chapter 810
• Use FECA Procedure Manual
• Gather All Facts in Case
• Investigate When You Have a Healthy Suspicion
• Do Not Speculate
• Send All Facts to U.S. Department of Labor -
  Nothing is Irrelevant
• Use ECAB Decisions in Your Dispute

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SOME TIPS

• Establish credibility with U.S. Department of
  Labor examiners
• Federal employees, not the enemy
• Dont criticize one claims examiner to another
  examiner. New evidence Send to DOL Supervisor
  to add to case
• Limited medical on card - C4 closure until we
  spend 1500
• At this point, OWCP has to open case and
  adjudicate
• CA-16 authorizes only 60 days of medical treatment

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COP

• Employees are entitled to COP when they are
  absent from work due to disability (when medical
  evidence which on its face supports disability
  due to a work-related injury and received within
  10 calendar days after claim is submitted) or
  medical treatment.
• Pay is continued for up to 45 calendar days.
  Leave will be counted against the 45 days. Leave
  does not extend COP entitlement.

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AA is given if sent home the DOI. Treatment
and/or AA is to be considered the first day of
disability

• If injury occurs before start of tour, COP will
  start at beginning of tour.
• Otherwise, COP begins with the first day or shift
  following the date of injury, provided that the
  absence begins within 45 days of the injury
• One hour counts as one day of COP

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When the effects of the injury results in
reassigning to the day shift to perform light
duty, COP should be granted for the lost
elements of pay (ND). Each day for which COP is
granted to cover lost elements of pay will count
as one full day of COP toward the 45-day limit.

• After the 45-day limit, the employee should apply
  for compensation to cover the lost elements. This
  should trigger a Rehab-Nurse from the DOL.

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• DOL will also now assign an RN during the COP
  period, if surgery is authorized or if you let
  them know the employee is on COP and will be
  going onto compensation and give them a date.
• Saturday and Sunday pay lost due to reassignment
  to week days is not payable under COP.

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• Any absence beyond COP time to be covered by
  leave, LWOP or AWOL, asappropriate
• If 45 days not used and employee suffers
  recurrence, may use COP if 45 days have not
  elapsed since first return to work. May continue
  past the 45th day deadline if uninterrupted
• If recurrence begins later than 45 days do not
  pay COP

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CONTROVERSION OF COP
An agency must continue pay unless at least one
of the conditions below applies

• The disability was not caused by a traumatic
  injury
• The employee is a volunteer working without pay
  or for nominal pay, or a member of the office
  staff of a former President

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The employee is not a citizen or a resident
of the United States or Canada

• The injury occurred off the employing agencys
  premises and the employee was not engaged in
  official off-premises duties
• The injury was proximately caused by the
  employees willful misconduct, intent to bring
  about injury or death to self or another person,
  or intoxication

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• The injury was not reported on form CA-1within 30
  days following the injury
• Work stoppage first occurred 45 days or more
  following the injury
• The employee initially reported the injury after
  his or her employment was terminated or
• The employee is enrolled in the Civil Air Patrol,
  Peace Corps, Job Corps, Youth Conservation Corps,
  Work Study Programs, or other similar groups.

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PAY MUST BE CONTINUED if claim is disputed
for reasons other than those above.

• For instance, on basis that the employee was not
  performing assigned duty when injury occurred, or
  that the condition is not the result of a
  work-related injury
• Any such objection should be supported by
  objective evidence such as pictures, time sheets,
  witness statements, first medical history given,
  or accident investigations

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WHEN TO DISPUTE CLAIM

• Need ROI for the medical records
• Pre-existing condition Temporary
  aggravation (Ask PMD when employee has returned
  to baseline)
• Constantly monitor the progress of case
• When initial agency medical evaluation differs
  from PMD

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Multiple statement differences

• Get statements from
  Safety Technician
  Supervisor Employee
  Witnesses
• EEOs and Grievances in Stress Claims
• (If Employee tells you of EEO or writes about it
  in claim)
• Performance Problems
• Low Leave Balances

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Recurrences Working for two months on job.
Has accepted job offer. Suitability decision
by DOL Has to prove material worsening to
receive disability

• Occupational Illness/Injury
• OWCP must have complete medical history (see
  checklists for occupational claims). If agency is
  aware that employee has been having problems
  prior to injury, ask employee to sign release of
  information to obtain that information.

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If they refuse, supply the information to OWCP
and they will request all the medical
documentation from the employee
Knowledge of a pre-existing condition is
important, as OWCP will want to determine when
claimant has returned to baseline.
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WHEN NOT TO DISPUTE

• Credible Witness
• Story is consistent
• Do not attempt to dispute every claim
• Concentrate on more difficult claims
• QUESTIONABLE
• When medical evidence shows quick recovery
• Able to send RTD with claim (in and out)

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STRESS CLAIMS
Stresses Not Covered

• Fear of a reduction in force
• Frustration from not being permitted to work in a
  particular job or environment
• Feeling of job insecurity
• Desire for a different job

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Stresses Not Covered (cont)

• Any personnel or administrative action
• Performance evaluations
• Any grievance or EEO claim/process (Send in all
  decisions)
• Must be no fault settlement

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STRESS CLAIMS
Stresses that are covered

• Emotional reaction to assigned duties
• Emotional reaction to requirements imposed by
  management
• Performance evaluations 1. If stress is due
  to an error 2. If stress is due to abuse
• Error and/or abuse in Personnel and
  administrative actions

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STRESS CLAIMS
Stresses that are questionable

• Harassment 1. Must have factual
  evidence 2. No
  decision on harassment is made by OWCP
• 3. Mere perception is not compensable
• 4. What are the facts involved?
• Discrimination - as above

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REASONS TO ATTEND HEARINGS

• It lets the Hearing Representative know that your
  agency has an interest in the case.
• It tends to keep the employee honest.
• The employees body language tells a lot.
• Knowledge of testimony, gives you time to gather
  information for your response to the testimony.
  Remember you only have 20 days from the date on
  the letter to you. You might receive it on the
  18th day.

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LIMITED DUTY

• JOB OFFERS
• LWEC
• (LOSS OF WAGE EARNING CAPACITY)
• AGENCY ROLE IN ADJUDICATION

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LIMITED DUTY

• A limited duty program accommodates injured
  employees who are temporarily unable to perform
  their regular functions/positions.
• A limited duty program has several advantages for
  injured employees as well as the agency
• 1. Employees normally recuperate more rapidly
  if they are as active as possible. Limited duty
  often helps to accelerate recuperation.
  
• 2. They retain the discipline of going to work
  every day. A long layoff often makes returning
  to work more difficult.

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3. While on limited duty, employees still
contribute to the organization and earn their pay.

• 4. Employees on limited duty assignments often
  prefer to return to their regular job as soon as
  possible rather than continue doing lesser
  skilled limited assignments.
• AN EARLY RETURN TO REGULAR DUTY IS THE ULTIMATE
  OBJECTIVE.

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PARTIAL DISABILITY

• A partially disabled employee who, without
  showing sufficient reason or justification,
  refuses to seek suitable work or refuses or
  neglects to work after suitable work has been
  offered to, procured by, or secured for the
  employee, is not entitled to further compensation
  for total disability, partial disability, or
  permanent impairment (Schedule award) as provided
  by sections 8105, 8106 and 8107 of the Act.

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PERMANENT DISABLITY

• When a permanently disabled employee who cannot
  return to the position held at the time of injury
  due to the residuals of the employment injury has
  recovered sufficiently to be able to perform some
  type of work, the employee must seek suitable
  work either in the Government or in private
  employment (see handouts for formal job offer).

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AGENCY RESPONSIBILITY

• Upon authorization of medical care, the agency
  shall advise the employee of his or her
  obligation to return to work as soon as possible.
• Where an agency has advised the employee of its
  willingness to accommodate, where possible, the
  employees work limitations and restrictions, the
  employee shall so advise the attending physician
  and request

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the physician to specify the limitations and
restrictions imposed by the injury. The employee
has the responsibility to advise the employing
agency immediately of the limitations and
restrictions imposed.

• The agency shall monitor the medical progress and
  duty status by obtaining periodic medical
  reports, such as the CA-17. The agency may
  correspond in writing with the employees
  physician concerning the work limitations and

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restrictions imposed. The agency is to
concurrently send copy of letter and answer to
OWCP

• The new DOL regulations state the agency cannot
  call the private medical provider.
• The Jacksonville District Office does not
  consider helping an employee arrange the initial
  appointment violates this rule.
• This rule was promulgated due to some agencies
  calling physicians trying to get them to change
  the duty status, etc.

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EMPLOYEE RESPONSIBILITIES

• Must submit prima facie medical evidence of
  traumatic disabling injury within 10 calendar
  days after claiming COP. Lack of receipt by
  agency is sufficient evidence to terminate COP,
  subject to reinstatement upon receipt of such
  evidence.
• An employee must immediately advise the agency of
  restrictions imposed by doctor.

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When offered duties within restrictions

imposed by physician, the employee is
obligated to return to duty.

• When an employee refuses an offer of suitable
  work, entitlement to COP ceases as of the
  effective date of availability of such work.
• If, under 5 U.S.C. 5584, OWCP finds that employee
  is not entitled to COP after it has been paid,
  the payments, at the employees option, shall be
  charged to annual, sick leave or LWOP
  (overpayment of pay).

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TEMPORARY LIMITED DUTY/PERSONNEL ACTION

• An offer may be made by phone but must be
  confirmed in writing in order to be valid it
  should include a description of the duties and
  requirements of the offered position. If a
  personnel action is involved, the employee must
  be furnished with a copy prior to the effective
  date. If the employee refuses to accept work
  offered, COP should be terminated as of the date
  of refusal, or after five workdays from the date
  of offer, whichever is earlier.

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• COP should be paid only if the employee has been
  assigned limited duty by formal personnel action
  and pay loss results. The COP dollar amount will
  be the difference between the pay rates of DOI
  job and the limited duty position.
• COP should also be paid if the limited duty
  consists of work at regular duties for fewer than
  the usually scheduled number of hours.

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FORMAL JOB OFFERS

• When injured worker can not return to job held
  Date Of Injury.
• Must be in writing and include
• 1. A description of the duties to be performed
• 2.The specific physical requirements of the
  position
• 3.The geographic location
• 4. The date on which the job will be available

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5. The rate of pay for the position6. The
date by which a response from the employee to the
job offer is required.A copy of the job offer
should also be sent to the DOL District Office.

• If accepted
• 1. Injured worker can immediately return to work
  (call OWCP to stop compensation).
• 2. Send job offer and acceptance to OWCP
• 3. Follow up for job suitability determination

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If declined

• 1. Send job offer and refusal to OWCP
  
• 2. Follow up for job suitability decision
  
• 3. Injured worker has 30 days to respond with
  reasons why not suitable
• 4. If OWCP still finds offer reasonable, the
  employee has 15 days to accept the job
• 5. COP should be terminated as of the date of
  refusal or after five workdays from the date of
  offer, whichever is earlier.
• 6. Compensation will continue until final decision

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LOSS OF WAGE EARNING CAPACITY FECA PROCEDURE
MANUAL 2-813 When an employee cannot return
to the date of injury job because of disability
due to a condition caused by the work-related
injury/disease, but does return to alternative
employment with an actual wage loss, the CE will
determine whether the earnings in the alternative
employment fairly and reasonably represent the
employees wage-earning capacity.
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• The CE will determine the claimants monetary
  entitlement utilizing the Shadrick formula (FECA
  PM 2-900.16). The comparison of pay rates between
  the DOI job and the new job will be done at the
  time that the formal LWEC decision is prepared.
• If the claimant returns to work at a retained
  pay rate, incurring no wage loss, the CE will
  issue a formal LWEC decision. Wages lost because
  step increases and/or cost of living increases
  were not applied to the retained pay rate do not
  constitute a loss of wage-earning capacity, and
  claims based on this premise should be denied.

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AGENCY ROLE IN ADJUDICATIONFECA Procedure
ManualChapter 2-810 9,b

• We recognize that an Agency does not adjudicate a
  claim. That is the DOLs function.
• We do have an important role. We are responsible
  for the investigation and submission of evidence
  when an employee claims an on the job injury.

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• The evidence may be in the form of medical
  reports from our physicians or lay evidence from
  supervisors, co-workers administrative personnel
  such as ourselves, investigative reports,
  pictures, etc.
• Our physicians medical opinions may not be
  considered a second opinion report for purposes
  of creating a conflict in medical evidence or for
  reducing or terminating benefits on the basis
  that the weight of medical evidence rests with
  this report.

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• Such a report must receive due consideration,
  however, and if its findings or conclusions
  differ materially from those of the treating
  physician, the CE should make an immediate second
  opinion referral.
• The CE cannot go to an Independent Medical Exam
  (IME) based on the opinion of an agency physician
• When a case is presented to a referee physician ,
  it contains all of the opinions expressed by all
  of the physicians involved.

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SUGGESTED RESPECTFUL REQUESTS (DO NOT DEMAND)

• This agency respectfully requests that your
  Office consider the above facts as you adjudicate
  this claim.
• We respectfully request that your Office give due
  consideration to Dr. _______s opinion, as
  prescribed in Chapter 2-810 of the FECA Procedure
  Manual.