# Presentation: 026838

## OWCP CASE MANAGEMENT

KATE CRAMER
OWCP PROGRAM MANAGER
VA MEDICAL CENTER
BAY PINES, FLORIDA 33744
    		(727) 398-9488 			

**	****	****	**
**KATE CRAMER**
**OWCP PROGRAM MANAGER**
**VA MEDICAL CENTER**
**BAY PINES, FLORIDA 33744**
**    ****	****	****(727) 398-9488**** ****	****	****	**

## CONTROVERSION OF COP

**DISPUTE OF CLAIMS**

**C O P**

**	****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 agency’s obligation to controvert an employee’s 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. **

## 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**

**Notes:**
Investigate all Monday morning (8:15am) injuries
Check for adverse actions, EEO’s, Grievances

## SOME TIPS

**Establish credibility with U.S. Department of Labor examiners**
** ****Federal employees, not the enemy**
**Don’t 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**

## 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. **

## 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

**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**

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

## 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.**

**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.**

**Any absence beyond COP time to be covered by leave, LWOP or AWOL, as****appropriate**
**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**

## CONTROVERSION OF COP

**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;**

**An agency must continue pay unless at least one of the conditions below applies:**

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

**The injury occurred off the employing agency’s premises and the employee was not engaged in official “off-premises” duties; **
**The injury was proximately caused by the employee’s willful misconduct, intent to bring about injury or death to self or another person, or intoxication;**

**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. **

##   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**

## 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**

**Notes:**
Can’t stress enough to concentrate on first medical history after injury.  If no mention of injury, the PMD cannot show causal relationship.

##  Multiple statement differences

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

## 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. ****	****	****	**

## If they refuse, supply the information to OWCP and they will request all the medical documentation from the employee

**If they refuse, supply the information to OWCP and they will request all the medical documentation from the employee**

## 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)**

## STRESS CLAIMS

**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**

_**Stresses Not Covered:**_

## Stresses Not Covered (cont):

_**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**

## STRESS CLAIMS

**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**

_**Stresses that are covered:**_

## STRESS CLAIMS

**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****	**

_**Stresses that are questionable:**_

## 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 employee’s 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.**

## LIMITED DUTY

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

## 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.**

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

**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.**

## 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.**

## 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).**

## 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 employee’s work limitations and restrictions, the employee shall so advise the attending physician and request**

## 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 employee’s physician concerning the work limitations and**** **

## 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.**

**Notes:**
VA does not agree that every supervisory official should be contacting the treating physician as stated in the Federal Regs.

## 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.**

##    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 employee’s option, shall be charged to annual, sick leave or LWOP (overpayment of pay).**

**Notes:**
Make sure the effective date is close to date PMD returns to limited duty.

## 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.**

**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.**

## 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;**

## 5. The rate of pay for the position;6. 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**

## 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**

## 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 employee’s wage-earning capacity.

**	****The CE will determine the claimant’s 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.**

## AGENCY ROLE IN ADJUDICATIONFECA Procedure ManualChapter 2-810 9,b

**We recognize that an Agency does not adjudicate a claim.  That is the DOL’s 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.**

**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.**

**	****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.**

## 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.**