- Introduction
- The Federal Employees Compensation Act (FECA)
- FECA's financial impact on the Department of Defense
- The Agency's input into the medical claim
- How medical input can impact the claim decision
- Back to work issues
- Why Occupational Medicine physicians should write opinion letters
- Keys to writing a good opinion letter
- Medical reference resources
- Representative letters
- Asbestos related disease
- Hearing loss
- Rotator cuff tears
- Chronic fatigue syndrome
Several years ago, the Commander of Naval Sea Systems Command (NAVSEA) initiated a program to limit the Navy’s liability for compensation costs that result from occupational injuries and illnesses occurring at his bases. A cooperative relationship began to develop between the injury compensation specialists at the Philadelphia Naval Shipyard (where the task force was set up) and the occupational medicine physician that was staffing the shipyard clinic. Together they began to place medical opinion letters into the claim file of workers that had spurious claims on the system. Over the course of the next few years, claims that would have cost NAVSEA millions of dollars were avoided because the Department of Labor (DOL) denied them, based on the medical input from the agency physician. During the last 6 years, more Navy Occupational Medicine physicians have participated in this process. The result has encouraged the Commander, Naval Installations in the continental United States (CNIC) which took the project over to expand the functions and to formalize the procedures for examining and controverting claims, and the medical input by Navy physicians has become a key element of this new system.
An article appeared in Navy Medicine in January 2007 that outlined the foundation for the cooperative system that is being built between Commander, Naval Installations (NCI-C) and the Bureau of Medicine and Surgery (BUMED). The recommendations that were outlined in the article were to:
- Implement a process to review claims
- Form a cadre of reviewers
- Create informational modules to facilitate reviews
- Track the quality/productivity of the reviews
The fundamental step in the process to review the claim had already been completed with the establishment of the centralized system at the Philadelphia Naval Shipyard FECA office. The system to solicit physician input and to track its effectiveness has been a work in progress. To date, the FECA office has implemented the following things in their tracking system:
- It tracks the number of claims sent out to physicians
- It records the turn-around time for the opinion letters
- It follows the case through the claim settlement process
- It will establish the amount saved (or not) after the Department of Labor settles the claim
- It provides feedback to the physicians
The purpose of this toolbox is to help accomplish two of the other goals that were outlined in the Navy Medicine article. We wish to create the informational module to facilitate reviews, and thereby encourage others to participate in the review process. This document is meant to provide our occupational medicine physicians with:
- a basic understanding of the Federal Employee’s Compensation Act (FECA)
- an appreciation of how they can help to manage the Department of Defense’s civilian employee workman’s compensation costs
- the motivation to get involved in the process
- tools to write effective medical opinions that will become a part of the patient’s claim record
The FECA was passed by Congress in 1916 and signed into law by President Woodrow Wilson. The FECA provides benefits for civilian employees of the United States who have suffered work-related injuries or occupational diseases. It is administered by the Office of Workers' Compensation Programs (OWCP), U.S. Department of Labor (DOL), through 12 district offices located across the United States. It covers all civilian employees of the United States, except those paid from non-appropriated funds. Special legislation provides coverage to Peace Corps and VISTA volunteers; Federal petit or grand jurors; volunteer members of the Civil Air Patrol; Reserve Officer Training Corps Cadets; Job Corps, Neighborhood Youth Corps, and Youth Conservation Corps enrollees; and non-Federal law enforcement officers under certain circumstances involving crimes against the United States. All kinds of injuries, including diseases caused by employment, are covered if they occur in the performance of duty, and diseases and illnesses aggravated, accelerated or precipitated by the employment are covered.
The primary benefits available to employees that are injured or made ill as a result of their employment are:
- Medical Benefits
- Services, appliances, and supplies prescribed or recommended by physicians which in the opinion of OWCP are likely to cure, give relief, reduce the degree or period of disability, or aid in lessening the amount of monthly compensation
- Includes examination, treatment, and related services such as medications and hospitalization, as well as transportation needed to secure these services
- Preventive care is not authorized
- Continuation of Pay (COP)
- Continuation of regular pay for up to 45 calendar days of wage loss due to disability and/or medical treatment after a traumatic injury
- The intent is to avoid interruption of pay while the claim is adjudicated
- Pay is subject to usual deductions from pay, such as income tax, retirement allotment, etc.
- Wage loss compensation
- Temporary Total Disability - continues as long as medical evidence supports total disability
- An injured worker who returns to work can receive compensation for time lost due to medical appointments, physical therapy, and/or reduced work hours based on medical restrictions
- The employee will receive 66.7% of salary without dependents and 75% of salary with dependents
- Schedule awards
- Compensation for specific periods of time for permanent loss, or loss of use, of certain members and functions of the body
- Partial loss or loss of use of members and functions is compensated on a proportional basis
- Must have reached maximum medical improvement before an award can be calculated
- Based on pay rate used for compensation purposes
- The employee will receive 66.7% of salary without dependents and 75% of salary with dependents
- Vocational rehabilitation
- Provides vocational rehabilitation services to assist disabled employees in returning to gainful employment consistent with physical, emotional, and educational abilities
- May be requested by attending physician, employee, or employing agency
- Compensation may be reduced or terminated for employee’s failure to participate or to make a good faith effort to obtain employment
- Loss of Wage-Earning Capacity
- When medical evidence shows an employee is no longer totally disabled and medical evidence determines s/he can perform duties of a lower-paying job, compensation is paid on the basis of loss of wage-earning capacity
- Compensation rate is 66.7% (without dependents) or 75% (with dependents) of the wage loss incurred as a result of the disability
- Death Benefits
- Survivors of Federal employee whose death is work-related are entitled to benefits including compensation payments, funeral expenses, and transportation expenses for the remains
- Eligible survivors include
- Widow or widower
- Unmarried child under 18 or over 18 if incapable of self support due to disability
- Child 18 – 23 who has not completed four years of post-high school education and is regularly pursuing full time course of study
- Parent, sibling, grandparent, or grandchild who was wholly or partially dependent on deceased
- Compensation rate is 50% of salary for surviving spouse, plus 15% for each surviving eligible dependent, up to 75% of salary
- Compensation continues for life of spouse, as long has s/he does not remarry before age 55
When a new claim for compensation is made against the government, the Defense Civilian Personnel Management System posts it online. It can only be accessed by approved personnel (the Injury Compensation Program Administrator (ICPA) handling the case is one of those people). Successful challenges to claims can reasonably be thought of as money you have saved the government. The actual cost-savings for a successful challenge will have to be obtained through the Department of Labor. However, you can use a calculator that is posted by the Civilian Personnel Management System to get a rough idea about how much money a claim might potentially cost the government: Cost Avoidance.xls. This calculator only addresses compensation for lost wages. The cost of medical expenses or scheduled awards would be added to the total cost of the claim.
The FECA costs are paid from the Employees' Compensation Fund, which OWCP administers. Each year, every agency employer reimburses the Fund for the amounts paid to its employees in workers' compensation benefits during the previous year. The DoD's portion of annual FECA costs represents approximately 25% of the total cost. In FY 2008, the dollars spent by the DoD for injury costs to civilian employees was $616 million (total federal cost was $2.67 billion). Of note, the Navy's chargeback cost has declined over the past three years while other Services' average chargeback has risen. In 2009, CNIC found that they had spent $14 million less in workers' compensation claims than they had anticipated.
The DoD’s Civilian Personnel Management Service (CPMS) is the agency responsible for managing DoD FECA claims. DODINST 1400.25M is the governing guidance in this process.5 The instruction allows for the command to review and advise CPMS as to what the DoD’s response to the medical issues should be.
SC810.3.5. Activity Medical Service
SC810.3.5.1. Medical Officers. Medical officers review all reported cases of occupational illness and take or recommend action. Upon the ICPA's request, they:
SC810.3.5.1.1. Provide medical information to be sent to OWCP to support or to controvert a claim for an occupational illness or work-related injury.
Getting a DoD physician involved in the process as early as possible, does a number of positive things.
- It provides the Injury Compensation Program Administrator (ICPA) with medical opinions that will help them decide whether to support or challenge the "work-relatedness" of a claimed injury or illness.
- It places another medical opinion in the claimrecord for the DOL claim’s processor to rely on when they make their decision in the case, and may help to speed up a valid claim’s approval
- It places another medical opinion in the claim record for the Employee Compensation Appeal’s Board (ECAB) judge to base a judgment on, if the claim is appealed.
- Failure to provide early input may allow a spurious claim to be approved. Once a claim is approved, it is more difficult for DOL to stop the continued payment of benefits.
- Once the Office accepts a claim and pays compensation, it has the burden of justifying the termination or modification of compensation benefits. This hold true where, as here, the Office later decides that it erroneously accepted a claim. Robert C. Fay, 39 ECAB ___ (1987); Thomas Lindsey, 39 ECAB ___ (1988); Hope J. Kahler, 39 ECAB ___ (1988).
As it stands right now, the ICPA may choose to consult the Occupational Medicine physician (AKA the agency physician) in order to help in a case. A close working relationship between the Occupational Medicine physician and the ICPA will help to get occupationally ill personnel back on the job more quickly, and it will help to cut down on the payments to employees that inappropriately receive compensation for injury or illness that is not occupationally related. There is currently a draft agreement in the works between the Army Medical Command and the Civilian Human Resources Agency. This document solidifies the relationship and responsibilities of the ICPA and the Occupational Medicine department, and it outlines joint responsibility for the program’s success. This type of relationship is not (as yet) so codified in the Navy, but it exists informally at some facilities.
BUMED has recently issued a policy memorandum that is the starting point for putting some structure into the program of using physicians to help ICPAs influence case decisions.
There are five essential elements that must be present in order for DOL to accept and pay an employee’s claim for medical costs and wage compensation.
- Was the claim submitted within a required time frame after the injury or illness occurred?
- Was the claimant a federal employee?
- Did the injury occur while performing assigned duties or engaging in an activity reasonably associated with the employment?
- Is there a diagnosed medical condition associated with the actual occurrence of an occupational accident or exposure?
- Is there a link between work-related exposure/injury and any medical condition found?
The diagnosis and the causality are determined on the basis of the attending physician's statement.
A medical connection between the injury and the condition found must be shown, and OWCP procedures limit those who can make these arguments in the process. Opinions of the employee, supervisors or witnesses are not considered, nor are general medical information in published articles. The fact that a condition appears during Federal employment does not establish causal relationship between the two. Likewise, the employee's belief that work factors caused or aggravated the condition does not establish causal relationship.
OWCP Procedure Manual 2-0805-3 states that “the question of causal relationship is a medical issue which usually requires reasoned medical opinion for resolution. This evidence must be obtained from a physician who has examined or treated the claimant for the condition for which compensation is claimed.” Paragraph (a) goes on to define the term “physician.” The term "physician" includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, osteopathic practitioners, and chiropractors within the scope of their practice as defined by State law. However, the services of chiropractors may be reimbursed only for treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist, except that a chiropractor may also provide services in the nature of physical therapy under the direction of a physician. A clinical psychologist may serve as the sole treating physician in cases where the accepted condition is wholly emotional in nature, but may not serve as the sole treating physician in cases that include a physical component unless the applicable State law allows clinical psychologists to treat physical conditions. A clinical psychologist may also perform testing, evaluation and other services under the direction of a medical doctor. By regulation, the term "qualified physician" does not include those individuals whose licenses to practice medicine have been suspended or revoked by a state licensing or regulatory authority or who have been excluded from payment under the FECA.
The portion of the procedure manual that states, “a physician who has examined or treated the claimant for the condition for which compensation is claimed” would seem to preclude Agency physician opinion letters from having an effect on the case, but the OWCP procedures also defines the Agency physician role in the process. OWCP Procedure Manual 2-0810-9(b) states “A physician who performed a fitness for duty examination of the claimant for the employing agency may not be considered a second opinion specialist for purposes of creating a conflict in medical evidence or for reducing or terminating benefits based on the weight of medical evidence. A report from such a physician 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 fact that our physicians do not always lay a hand on the Claimant is also addressed in the OWCP procedures and it makes the fact immaterial. OWCP Procedure Manual 2-0810-4(c) states that “Once all opinions are evaluated, they must be compared. The fact that one physician examined the claimant while the other did not is insufficient to tip the scale either way. However, had the opinion of the physician who examined the claimant not been rationalized, the opinion of the physician who had not examined the claimant would have represented the weight of the medical evidence since it was rationalized. In a particular case, the fact that the physician had not examined the claimant may be mitigated by the fact that the issue of causal relationship is frequently not one that requires physical examination.”
Most importantly, the fact that the letter is present in the case file means that the claim examiner must read it. OWCP Procedure Manual 2-0810-12(b) states that “the CE must address all medical evidence of record as it relates to the issue at hand. If the issue is causal relationship, the memorandum or decision should note those physicians who did not comment on causal relationship and find that these reports had no evidentiary value on that issue. The memorandum or decision would note all other physicians' opinions and discuss their relative merits based on whether the opinions were vague or firm, reasoned or unreasoned, and well-founded or not, within the context of the physicians' respective training and qualifications.”
It is difficult to say that the issue of diagnosis and causality turn on our opinions. We can say that a reasoned opinion letter can lay a path for the claims examiner to follow in deciding the case, based on those arguments derived from the medical records. These letters are also read by others, including the District Medical Advisor and a physician that might be doing a second opinion or referee examination at some future date. The early indications are that the program has succeeded in saving the Navy money. From August 2006 until February 2008, 122 cases have been reviewed and letters written for insertion into the claim file. On cases that have been decided one way or the other, the amount of money that the CNIC Workers’ Compensation Office has computed to have been avoided is $9.04 million. There is written evidence that the Office of Workers’ Compensation at the Department of Labor and the Employee Compensation Appeals Board is reading these medical opinions. The following are some examples of case decision letters where Agency physicians’ opinions have been cited in the text.
Many facilities use FECA Working Groups (FWG) to help monitor FECA costs at their command. The FWG is supposed to have a representative from Occupational Health involved in the group, and this is a good first step to process of managing costs. It would be better for the command’s Occupational Medicine physician to have early input into the work restrictions that an employee’s physician puts on the employee after an injury or illness (that they claim to be work related). This can be the key to how much money will eventually be spent on the case.
It can be expected that the majority of claims are legitimate occupationally-related injuries and illness. You should expect that the restrictions placed on the worker are reasonable. However, if this is not the case, then the commander’s Occupational Medicine physician can be an aid to the Injury Compensation Program Administrator, in order to get the claim handled appropriately in the Department of Labor and to get the employee back to work. Difficult cases require a team approach to manage. It requires a good working relationship between the Occupational Medicine physician, the employee’s supervisor, the Human Resources department, and it might require good communication with the patient’s physician. This is another role that the Occupational Medicine physician is uniquely qualified to fulfill.
DOL rules and DoDI 1400.25-M require that communication with the patient’s physician be in writing. Although DOL frowns on it, verbal communication between the agency physician and the patient’s physician may help to expedite matters, but all conversations should have follow-on letters and/or forms to document the encounter. Written correspondence can be by U.S. mail, fax, or e-mail.
Medical surveillance and fitness for duty are both very important features of the Occupational Medicine role, but the biggest economic impact (and the most visible role to military leadership) that the Occupational Medicine physician can play is by having an effect on the FECA bill. Early intervention in an occupational injury or illness claim could make a large economic impact for the command where you are stationed. This cost savings (if you can effect it) should be tracked, and the command should be made aware of what the Occupational Medicine physician is doing to keep people at work, hold medical costs and disability compensation down, and thereby saving the government money.
The keys to a medical opinion from the Activity Medical Officer that is useful to move the claims process forward are that it is timely, decisive, and fair. Reviews should incorporate “an evidence-based medicine approach that includes appropriate medical literature references.” To that end, this toolbox provides the interested physician with a number of different resources to help them.
The link shown below are two example letters that were presented in a lecture given at the 2006 Army Force Health Protection Conference. They provide the elements of a good (and a bad) medical opinion letter. It demonstrates elements that Department of Labor claims evaluator’s feel are important in helping to move (or not move) a case forward.
More letters that have been written by other physicians are included in the case toolboxes below.
Current Medical Literature
If you ever attended the Uniformed Services University of the Health Sciences (USUHS), than you have access to the National Library of Medicine’s PubMed database. The Resource Learning Center will provide former students, faculty, and staff with access to their on-line journal system for life. The library also has a generous subscription service that allows the users of the service to view and download electronic versions of articles that pertain to the cases being addressed. The library service will also scan and forward articles that are only available in the library’s holdings or that can be obtained through interlibrary loan services. These services must be obtained by request, and this may also be done on-line through the Resource Learning Center website. Articles that have been cited by other physicians appear in the sample letters listed (by diagnosis) below. The USUHS Learning Resource Center website address is: http://www.lrc.usuhs.mil/lib/main.lasso . Most Navy medical treatment facilities have a similar service through their medical library. In any case, access to PubMed is key to writing good medical opinion letters.
Electronic Textbook Resources
The USUHS Learning Resource Center also has an extensive library of on-line textbooks available to those physicians that have access to the system. Currently, there are over 75 textbooks available, and they cover all areas of medicine. The on-line textbooks are available at the same USUHS web address listed above. The site has an excellent search engine associated with the library of textbooks, and it allows the user to scan the entire database for specific words that might point to the topic they wish to explore.
For those without USUHS access, StatRef® is another internet based library that is available to Navy physicians through the Naval Medical Information Management Center. It provides access to the most current editions of 38 different textbook sources.
Information on specific subjects can be also be accessed using a search engine.
This is a listing of the current reference books available through StatRef®, and they cover a wide base of medical specialties.
Reference Book Titles Available For Use in StatRef®| 5-Minute Clinical Consult 2007, The - 15th Ed. | AAFP Conditions A to Z (2006) |
| ACP Medicine (2007) | ACP's PIER: The Physicians' Information and Education Resource (2007 |
| ACS Surgery: Principles & Practice (2007) | AHFS Drug Information® (2006) |
| Basic and Clinical Pharmacology - 9th Ed. (2004) | Control of Communicable Diseases Manual - 18th Ed. (2004) |
| Current Critical Care Diagnosis & Treatment - 2nd Ed. (2003) | Current Diagnosis & Treatment in Cardiology - 2nd Ed. (2003) |
| Current Diagnosis & Treatment in Gastroenterology - 2nd Ed. (2003) | Current Diagnosis & Treatment in Orthopedics - 4th Ed. (2006) |
| Current Diagnosis &Treatment in Pediatrics - 18th Ed. (2007) | Current Diagnosis &Treatment Obstetrics & Gynecology - 10th Ed. (2007) |
| Current MedicalDiagnosis & Treatment - 46th Ed. (2007 | Davis's Drug Guide forNurses - 10th Ed. (2007) |
| Diagnostic and Statistical Manual - Text Revision (DSM-IV-TR™, 2000) | Diseases and Disorders: A Nursing Therapeutics Manual - 3rd Ed. (2007) |
| Emergency Medicine: A Comprehensive Study Guide - 6th Ed. (2004) | Essentials of Oral Medicine (2002) |
| Family Medicine: Principles and Practice - 6th Ed. (2003) | Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology - 5th Ed. (2005) |
| Geriatric Medicine: An Evidence Based Approach - 4th Ed. (2003) | Goldfrank's Toxicologic Emergencies - 8th Ed. (2006) |
| Goodman & Gilman's The Pharmacological Basis of Therapeutics - 11th Ed. (2006) | Harrison's Principles of Internal Medicine - 16th Ed. (2005) |
| ICD-9-CM - Volumes 1, 2, and 3 (2007) | Ingenix® CPT with RVUs Data File (2007) |
| Merck Manual of Diagnosis and Therapy, The - 18th Ed. (2006) | Red Book®: 2006 Report of the Committee on Infectious Diseases - 27th Ed. |
| Review of General Psychiatry - 5th Ed. (2000) | Review of Medical Physiology - 22nd Ed. (2005) |
| Review of Natural Products (2007) | Rudolph's Pediatrics - 21st Ed. (2003) |
| Smith's General Urology - 16th Ed. (2004 | Treatments of Psychiatric Disorders - 3rd Ed. (2001) |
| USP DI® Advice for the Patient® - 27th Ed. (2007) | USP DI® Drug Info. for the Health Care Pro. - 27th Ed. (2007) |
| Williams Obstetrics - 22nd Ed. (2005) | Women's Health: A Primary Care Clinical Guide - 3rd Ed. (2004) |
It may be accessed at http://www.statref.com . You will need the user name and password to access the system.
BUMED has obtained a user license forThe Medical Disability Advisor, 5th edition. User names and passwords for on-line use of this text are available through the Public Health Directorate at BUMED. The point of contact is CAPT Neal Naito. https://www.mdainternet.com/NavyCustomers/index.html
One other very important book that will help in writing these letters is (currently) not available from these sources. The American Medical Association’s Guide to the Evaluation of Permanent Impairment, 6th edition should be obtained before starting the process of addressing the claim issues.
This portion of the FECA toolbox is organized by specific diagnosis, and it is intended to make the physician aware of how others have approached the subjects in the past. It is not intended to be a rigid set of guidelines for writing these letters, but these letters have been helpful to case managers in the past. Most of them have been successful in (either) supporting or challenging FECA claims. The patient names and identifying numbers have been removed from the text. The list of letters has grown over time, and the process of writing successful opinion letters is an interactive one. New peer-reviewed research articles appear in the literature all the time, and everyone benefits from the communication of the newest information available on a specific problem. We hope that this toolbox concept will grow and become more useful as new users of the site add their expertise to the pool of representative letters.
Each toolbox includes representative case letters, pertinent peer-reviewed articles that have proven to be useful, and Employee Compensation Appeal Board (ECAB) decisions that are directed toward aspects of the specific types of cases. The ECAB decisions are included in the case toolboxes to help the physician to see how the cases have been decided in the past. The complete case decision can be accessed by going to the Department of Labor website at: http://www.dol.gov/ecab/decisions/main.htm, but the complete case file postings are limited to certain years. It is much easier to search for cases that pertain to the subject being researched if they are accessed through the use of the cyberFEDS® site. This resource is available by subscription, and the access is also controlled through BUMED’s Public Health Directorate. http://www.cyberfeds.com/CF3/splash.jsp
Physicians should be warned that the ECAB has made one thing very clear in decisions that they have made in the past.
- Physicians should not quote labor law in their medical opinions
- Lawyers should not interpret medical facts
However, it is helpful to see how the courts have handled certain aspects of medical claims when writing these medical opinion letters.
Asbestos Related Diseases: Toolbox-Asbestos exposure and asbestosis.doc
Hearing Loss: Toolbox-Hearing Loss.doc
Rotator Cuff Tears: Toolbox-Rotator Cuff Tears.doc
Chronic Fatigue Syndrome: Toolbox-Chronic Fatigue Syndrome.doc
Carpal Tunnel Syndrome: Toolbox-Carpal Tunnel Syndrome.doc
References
- Lankin K, et al. “Mustering the Fighting Strength.” Navy Medicine. January-February 2007; pages
- Nordlund WJ. The Federal Employee’s Compensation Act. Monthly Labor Review. September 1991; pages 2-14.
- DeCarlo L. Workers An Overview of Office of Workers’ Compensation Programs (OWCP) Lecture delivered at 2007 NEHC Conference, Hampton VA; March 2007.
- Source: U.S. Office of Management and Budget. Accessed at: http://www.whitehouse.gov/omb/expectmore/detail.10000334.2005.html
- Source: CPM81027Sep05.pdf
- Naito N. Workers Compensation Medical Review Consultations. Lecture delivered at 2006 NEHC Conference, Hampton VA; March 2006.
Content last reviewed on April 15, 2010.