office of workers’ compensation. topics to be covered overview of the federal employees’...

Office of Workers’ Office of Workers’ CompensationCompensation

Topics To Be CoveredTopics To Be Covered

• Overview of the Federal Employees’ Compensation Act (FECA)

• Primary Benefits Provided under the FECA

• Types of Injuries and Initiating Claims

• Conditions of Coverage

• COP and Controversion

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• Supervisor Responsibilities

• Containing OWCP Costs

• Automated Systems

• Internet Resources and References

Topics To Be CoveredTopics To Be Covered

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Overview of the FECAOverview of the FECA

• Federal Employees’ Compensation Act (FECA) passed in 1916

• Benefits Provided

• Remedial in nature

• Non-adversarial – an attorney is not required

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Overview of the FECA Overview of the FECA (cont’d)(cont’d)

• Program Administration

• DOL / OWCP Adjudicates Claims

• Privacy Act

• HIPAA

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Primary Benefits Provided under the FECAPrimary Benefits Provided under the FECA

• Medical Benefits

– Treatment of Injury

– Preventive care is not authorized

– Fee Schedules

– Chiropractor

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Primary Benefits Provided under the FECAPrimary Benefits Provided under the FECA

• Continuation of Pay (COP)

– Intent is to avoid interruption of pay while the claim is adjudicated

– 45 calendar days

– Traumatic Injury - ONLY

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Primary Benefits Provided under the FECAPrimary Benefits Provided under the FECA

– Traumatic Injury

– Occupational Disease Claim

– Death

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Primary Benefits Provided under the FECAPrimary Benefits Provided under the FECA

• Schedule awards

• Vocational rehabilitation

• Death Benefits

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Conditions of CoverageConditions of Coverage

– Timely Filing of Claim

– Federal Civil Service Employee

– Fact of Injury

– Performance of Duty

– Causal Relationship with medical

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Timely FilingTimely Filing

• Employee Has Three Years From:

– Date of Injury

– Date of First Awareness

– Date of Last Exposure

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Civil Service EmployeeCivil Service Employee

• FECA covers all Federal Civil Service and Federal Civilian Employees except for non-appropriated fund employees

• Temporary employees covered on the same basis as permanent employees and indefinite

• Contract employees, volunteers, and loaned employees are covered under some circumstances

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Fact of InjuryFact of Injury

• Factual – Actual occurrence of an accident, incident, or exposure in time, place, and manner alleged

• Medical – Medical condition diagnosed in connection with that accident, incident, or exposure

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Performance of DutyPerformance of Duty

• Injury occurred while performing assigned duties or engaging in an activity reasonably associated with the employment

• Injury occurred on work premises

• Injury occurred off premises while engaging in work activity

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Causal RelationshipCausal Relationship

• Link between work-related exposure/injury and any medical condition found

• Based entirely on medical evidence provided by physicians who have examined and treated the employee

• Opinions of employee, supervisor, or witnesses not considered – nor is general medical information contained in published articles

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Statutory ExclusionsStatutory Exclusions

• Willful Misconduct – deliberate and intentional

disobedience of rules/orders – not carelessness

• Drug or Alcohol Intoxication – proximately caused the

injury

• Intent to Injure Self or Others – intent must be

established

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Initiating A Claim for a Traumatic InjuryInitiating A Claim for a Traumatic Injury

• Traumatic Injury

– Wound or other condition of the body caused by external force, including stress or strain

– Caused by specific event or series of events or incidents within a single day or work shift

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Initiating A Claim for a Traumatic InjuryInitiating A Claim for a Traumatic Injury

• Notice of Traumatic Injury – CA-1

– Employee (or someone on her/his behalf, including supervisor) completes front

– Supervisor completes back

– Must be submitted to employing agency within 30 days of date of injury to be eligible for COP – however can be submitted up to three years after the injury

– Must be transmitted to OWCP within ten workdays from date agency received form – DO NOT HOLD for wage calculations, supporting documentation, etc.

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Supervisor’s Role related to a Traumatic Injury ClaimSupervisor’s Role related to a Traumatic Injury Claim

• Have employee seek medical attention.

• Discuss and review the facts surrounding the incident. Report injury or illness to safety and HRO.

• Complete the supervisor and safety screens within the EDI for CA-1 or CA-2 and submit to the HRO.

• Advise employee of her/his responsibility to submit medical evidence of disability within 10 work days, claim on file within 30 work days of injury or risk termination of COP

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Initiating A Claim for a Occupational DiseaseInitiating A Claim for a Occupational Disease

• Occupational Disease

– Condition produced over a period longer than one

workday or shift

– Exposure over time longer than one workday

– Authorize medical care, process CA-2

• COP is not provided for Occupational Diseases

• CA-16 is not issued for Occupational Diseases

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Supervisor’s Role related to a Occupational Supervisor’s Role related to a Occupational Disease ClaimDisease Claim

• Review the employee’s portion of the form and provide comments concerning the employee's statement

• Supply supporting documents if available

• Advise employee of the right to elect sick, annual leave or LWOP, pending adjudication of the claim

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Wage Loss/Permanent ImpairmentWage Loss/Permanent Impairment

• An employee who can not return to work when COP ends or who is not entitled to COP may claim compensation for wage loss on CA-7

• An employee who has returned to work but who still requires medical treatment during work hours may claim compensation for lost wages while undergoing or traveling to and from treatment

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CA-7CA-7(Claim for Compensation)(Claim for Compensation)

• An employee who uses annual or sick leave to avoid interruption of income may repurchase that leave, subject to agency concurrence, if the claim is approved

• Claim for compensation of loss wages

• Request Schedule awards for permanent impairment

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CA-16CA-16Authorization for ExaminationAuthorization for Examination

• Covers the member for medical billing purposes for 60 days of coverage.

• Form is used for injuries requiring follow up treatment.

• Member / Supervisor completes first copy, Provider completes second copy, forward back to HRO.

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CA-17CA-17 (Duty Status Report)(Duty Status Report)

• Interim medical report about employee’s fitness for duty and

work capabilities

• May be issued initially with CA-16

• Supervisor/Agency completes agency portion by describing

physical requirements of the employee’s job and noting the

availability of light or limited duty

• Agency can send to physician at any time during life of claim –

but not more than once a week

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CA-20CA-20 (Attending Physician’s Report)(Attending Physician’s Report)

• Submitted to OWCP along with CA-7 for wage loss or leave buy back

• Requests information on diagnosis, prognosis, history of injury, prima facie statement of causal relationship, etc.

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Challenging Validity of ClaimChallenging Validity of Claim

• Investigate circumstances and report results to HRO

• Include specific evidence: witness statements, accident investigations, timecards

• Must be supported by specific factual evidence

• Attach detailed statement describing circumstances behind challenge

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APPEAL RIGHTSAPPEAL RIGHTS

ORAL HEARING WITHIN 30 DAYS

RECONSIDERATIONWITHIN 1 YR

ECAB APPEAL BOARD WITHIN 180 DAYS

FROM DATE OF DECISION

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PENALTIESPENALTIES

• Anyone who knowingly and willfully falsifies, conceals or covers up a material fact;

• Makes a false, fictitious, or fraudulent statement or representation may be subject to these penalties:

A. FINEB. 10 YEARS IMPRISONMENTC. BOTH

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Initiating a Claim for Death BenefitsInitiating a Claim for Death Benefits

• When an employee dies because of an injury incurred in the performance of duty, the supervisor/agency should immediately notify the district office via phone or fax

• The supervisor/agency should contact any survivors, provide them with claim forms, and help them prepare the claim

• CA-5 or CA-5b used to submit claims for death benefits

• Supervisor/Agency uses form CA-6 to report the work-related death of an employee

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Containing OWCP CostsContaining OWCP Costs

• Challenge Questionable Claims

– OWCP accepts employee statement as factual unless agency provides refuting evidence

– Agency does not have post adjudicative appeal rights

– Include actual evidence rather than conjecture or opinion

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Containing OWCP CostsContaining OWCP Costs

• Offer Light Duty

– Match employee’s physical limitations to your particular position needs

– Can be reassigned to temporary position

– Benefits of offering light duty:• improves morale for both injured worker and remainder

of workforce

• each day employee remains out of work reduces

likelihood s/he will ever return

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QUESTIONS?QUESTIONS?

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AGENCY WEBSITE http://dmna.ny.gov/hro/

General information on OWCP: http://www.dol.gov/esa/regs/compliance/owcp/fecacont.htm

ACS website (bill processing and authorization information):http://owcp.dol.acs-inc.com/portal/main.do

ACS Customer Service: (850) 558-1818

ACS Bill payment/reimbursement/authorizations: (866) 335-8319

Your Injury Compensation Program Administrators (ICPA):SGT Stephen Clemente 518-786-4727stephen.a.clemente.mil@mail.mil

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OWCP Additional Information