office of workers’ compensation. topics to be covered overview of the federal employees’...
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Office of Workers’ Office of Workers’ CompensationCompensation
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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 [email protected]
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OWCP Additional Information