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# **LONG TERM CASE MANAGEMENT**

## **Presented by:**

## **Esther Easter, Internal Revenue Service**

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#  

# **Where and How do you Start?**

## ***Review your charge back listing***

## 

## Verify ownership

## If you can't verify ownership, request a copy of the CA1 or CA2 from OWCP

## Analyze the costs associated to the case (both medical and compensation)

## Target your groups

## 

## ***How to prioritize your Cases***

## 

## Group 1 - Injured less than 2 years, any age

## Group 2 - Injured more than 2 years, under age 60

## Group 3 - Over age 60

## Consider the injury sustained - strains and sprains first, then to the more extensive injuries

## Consider the physical requirements of the date of injury position

## 

## **Give your cases a Rating**

## 

## Rating 1 - Compensation can be terminated with 6 months

## Rating 2 - Compensation can be terminated within 6 to 12 months

## Rating 3 - Possible potential for re-employment

## Rating 4 - Little to no potential for re-employment

## 

## 

## ***Start with Group One Cases with Highest Rating***

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## Obtain the most recent medical evidence 

## Obtain the date of injury (DOI) job description

## Determine if the DOI employer is capable of re-employment

## Determine what type if any job modification may be needed and if the modification would be feasible

## 

## ***Develop your Plan***

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## Remember that OWCP has limited resources so you will want to pursue cases with the most potential for savings. 

## To this end you will need to begin analyze the medical and factual evidence of record and begin to develop your plan.

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## ***Reviewing Medical*** 

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## Determine if the restrictions are "temporary" or "permanent"

## If temporary, it may be in the best interest of the claimant and the employer to "wait out" any remaining disability. Our ultimate goal should be to "mainstream" as many of our injured employees as possible, in lieu of "creating" some work on a short-term basis

## If permanent, how "severe" are the restrictions? Would developing a modified job offer create an undue hardship on the employer? 

## 

## ***Return To Work Potential***

## 

## Identify current employer status, I.e., "open" Vs "closed"

## If open, provide medical restrictions and pertinent claim and employee data. (See RTW letter in handout)

## Follow-up within 7 days to identify any potential obstacles for returning employee to suitable employment within the medically defined restrictions

## Additional follow-up should occur 14 days from initial request.

## If closed, discuss potential options using vocational rehabilitation services with the claims examiner.

## Consider the educational background of the employee, current market availability, and possible "assisted reemployment" with another employer.

## Continue follow-up with the OWCP during the vocational rehabilitation process until you have resolution, i.e., actual return to work, constructed LWEC based on potential earnings.

## 

## ***Possible Fraud Identification***

## 

## Review the information from your review of the OWCP case file for "Red Flags":

## "Multiple" change of address notices

## Field Nurse/Vocational Rehabilitation Counselor notes indicating an "inability" to communicate with the claimant

## Statements made by a physician/physical therapist relating to "has been very active over the summer", "has experienced an increase in pain on occasion while sitting the grandchildren"

## 

##  ***Elements of an OWCP claim***

## A + B = C

## A occurrence of injury event

## + causal relationship 

## B medical condition

## C OWCP claim

##  

## *A causal relationship exists when there is a connection between the work-related injury event and a medical condition.*

##  

## ***Direct Causation***

## Piece of equipment drops on foot resulting in toe fracture

## Lifting bag of mail and sustains low back strain

## Slips on ice and sustains concussion with amnesia

## 

## ***Aggravation***

## Paint fumes worsens pre-existing asthma (temporary)

## Ankle strain exacerbates cartilage damage in knee with pre-existing degenerative arthritis (permanent)

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## ***Acceleration***

## Sexual harassment by supervisor provokes heart attack in female worker with high blood pressure

## Perforation of eardrum hastens the onset of significantly impaired hearing

## Continual requirement of lifting accelerates a degenerative condition

##  

## ***Precipitation***

## Diabetic in good control develops CTS and is given oral steroids which causes severe hyperglycemia and subsequent hospitalization

##  

## *Sometimes an injury occurring outside of the performance of duty may affect the compensability of a work-related injury.*

## **[Consequential Injury]{.underline}** is a [new]{.underline} injury which occurs as the "direct or natural result" of a work-related injury (absent any "independent intervening cause")

## - a diabetic develops an infection in a crushed toe which requires amputation of the toe

## - a worker develops a low back strain while limping from an ankle fracture

##  

## **[Intervening Injury]{.underline}** is a [new]{.underline} injury, which occurs to the same part of the body originally injured. The resulting condition will be considered related to the original injury unless the second injury alone is established as its cause.

## i.e. a ligament tear occurs days later after a work-related knee strain 

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## **Primary Goal**

## 

## *Remember the Primary Goal is to lower OWCP costs by decreasing the number of cases on the periodic roll.*

## 

## **Periodic Rolls**

## Death

## Resignation

## Medical Retirement

## Termination of Benefits

## Return to work in same/similar position 

##  

## Always be cognizant of the concept of Maximum Medical Improvement (MMI) when reviewing documentation. 

## MMI implies that the employee has reached his/her maximum extent of recovery and no further improvement can be expected. Also referred to as "permanent and stationary".

## 

## When the medical evidence shows that [total]{.underline} disability has ended, strongly consider returning the claimant to work:

## 

## -To position held at time of injury with modifications to accommodate limitations

## -To another position at the same salary as the position held at time of injury

## -To another position at a lower salary than the position held at time of injury

## 

## Fundamental Consideration

## 

## "A partially disabled employee who\-\--

## refuses suitable work; or 

## refuses or neglects to work after suitable work is offered to, procured by, or secured for him; is not entitled to compensation"

## Title 5, Subchapter 1 -- 8106

## 

## ***Communications***

##  

## Keeping in touch with all parties involved is paramount in managing compensation claims

## Communications should be effective and useful and never routine or redundant 

## Interaction with all parties should demonstrate an interest in the injured worker (IW) and the progression of the IW's condition

## 

## ***With whom should you be communicating?***

## 

## Injured worker

## Supervisor and other interested parties within the organization

## Attending Physician

## OWCP Field Nurse

## OWCP Claims Examiner

## OWCP Vocational Rehabilitation Counselor

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## **Keeping in touch with the injured worker**

## 

## Federal agencies have been widely criticized for their failure to communicate with injured workers.

## Provide the IW with a point of contact and a telephone number for the ICPA

## Keeping a line of communication open with the IW assures that they have a resource should problems arise in their claim

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## ![](media/image2.wmf)

## ***Communications within the Employing Agency***

## 

## Discuss and assist in the development of a light duty or alternative work assignments within the IW's activity

## Develop a FECA Working Group, which meets periodically to analyze FECA costs, trends, plans, etc.

## 

## ***Corresponding with the Attending Physician***

## 

## All communications with the attending physician must be in writing

## Ask pertinent questions

## Only write after you know the physician will be able to provide updated information, i.e. after a course of therapy, a second opinion, or following an office visit

## 

## ***Obtaining Medical Updates*** 

## You can check AQS to see if claimant has been seen by his physician recently

## Remember OWCP only requires medical updates from the IW as follows:

## PR Cases - Every Year

## PW Cases - Every 2 Years

## PN Cases - Every 3 Years

![](media/image3.wmf){width="1.6784722222222221in"
height="2.279861111111111in"}

## ***Working with OWCP Personnel and Contractors***

## 

## In the early phases of a disability claim, working with the OWCP Field Nurse and Rehabilitation Counselor is extremely important - Remember there is a time limitation, so you'll want to be responsive in order to obtain as much benefit as possible from their services. Let it be known if you are unable to accommodate a partially disabled IW so OWCP can move on to the next phase

## 

## ***Communications with the Claims Examiner***

## 

## A Claims Examiner (CE) has a large case load - Give them an opportunity to respond

## If you obtain medical evidence which indicates IW is only partially disabled write to CE requesting intervention

## Clarification from AP on restrictions

## Rehabilitation Referral

## 2nd opinion referral

## ![](media/image4.wmf)If a 2nd opinion evaluation supports total disability, remember the CE cannot refer the IW out again for an evaluation for an appropriate period of time (usually 1 year) 

## Don't request actions by CE which will have no relevance in the overall claim

## Be responsive to requests for information received from OWCP

## 

## ***Final Thoughts***

## 

## Develop a good working relationship with all involved parties. Badgering a CE or a doctor's office is really counterproductive 

## Remember this is a team effort even if the end responsibility rests with OWCP

## Our ultimate responsibility is to ensure that an injured worker receives the proper benefits under the law

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