OWCP Claim Acceptance & Minimal Diagnosis

Federal Workers Compensation Coffee Break Podcast is about all things related to Federal Workers Compensation, FECA, OWCP, DOL & Longshore claim filing as an injured federal worker.  The podcast is an educational and informative training on how to navigate the DOL -OWCP claims filing process for all types of injured US government and federal workers. The podcaster has 27 years in assisting with federal workers compensation as a consultant and trainer. The podcast is free and is educational. If you need help with anything related to a federal workers compensation claim...help is just a cup of coffee away.

If you are a federal worker that has a federal workers compensation claim either as a traumatic injury CA-1 or as a CA-2 occupational illness or injury and you submit your CA forms, Ca-1, Ca-20 and/or CA-16, Ca-17 and a written statement….either by mail or ECOMP. OWCP will provide you with an explanation of acceptance and/or denial by mail and /or ECOMP.  

 If either the your physician or you, the injured federal worker  believe  that the accepted conditions require expansion or modification to be more accurate, OWCP will request a detailed explanation as to how the additional conditions are related to the original work-related injury or resulting residuals.

 Most claims are denied with a 5 elements letter and lists which of the 5 elements were not met with an explanation why your claim is denied and advise you fully of your appeal rights, including the time frames for exercising these rights and the offices you should contact and lastly how to appeal the denial decision. I often have to explain to patients that the fight to get your full claim with all of your accurate diagnosis included needs to be continued and submitted. When you the federal worker receive an OWCP acceptance letter an alarm bell should sound off in your head if your acceptance letter only lists minimal diagnosis of bruises and strains. Often times when an intake medical provider sees an orthopedic injury the diagnosis is initially strain, sprain and or pain, swelling or contusion. This is due to the fact that the amount of damage or severity and location of the tearing of muscles, ligaments and tendons has not been confirmed more definitively by x-rays, CAT scans or MRIs. So, pay close attention to your first acceptance letter and make sure if you have a more severe injury you present the medical evidence from an OWCP approved medical provider that contains an expansion diagnosis narrative with supporting diagnostic tests along with a strong causation statement explanation.
Dr. Taylor's educational podcast utilizes his experience and history as a DOL - OWCP provider and his years of consulting and teaching all things federal workers compensation related. This is an educational short form format for learning how to successfully file federal workers compensation claims. So grab a cup of coffee and lets begin.

Dr. Taylor's contact information for more information or assistance is:
https://fedcompconsultants@protonmail.com

If you need an OWCP approved medical provider, You can make a  a consultation with me to discuss your case or if you know someone in Tampa or Pensacola Florida and south Mississippi, Georgia or Alabama,  who is recently injured you can call the clinic at

Transcript

If you are a federal worker that has a federal workers compensation claim either as a traumatic injury CA-1 or as a CA-2 occupational illness or injury and you submit your CA forms, Ca-1, Ca-20 and/or CA-16, Ca-17 and a written statement….either by mail or ECOMPed. OWCP will provide you with an explanation of acceptance and/or denial by mail and /or ECOMP.  

–        If either the your physician or you, the injured federal worker  believe  that the accepted conditions require expansion or modification to be more accurate, OWCP will request a detailed explanation as to how the additional conditions are related to the original work-related injury or resulting residuals.

Most claims are denied with a 5 elements letter and lists which of the 5 elements were not met with an explanation why your claim is denied and advise you fully of your appeal rights, including the time frames for exercising these rights and the offices you should contact and lastly how to appeal the denial decision. For review… the 5 elements that are required to be met are the following:

1.       Be Timely Filed. not later than 30 days from the date of injury (DOI) in order to be entitled to a benefit called Continuation of Pay (COP). Otherwise, the employee has up to three years to file a claim

2.       Be made by a Federal civilian employee. Must work for the government in some capacity.

3.       Establish Fact of Injury, which has both a factual and medical component. Factually, the injury, accident or employment factor alleged must have actually occurred. Medically, a medical condition must be diagnosed in connection with the injury or event.

4.       Establish Performance of Duty. The injury and/or medical condition must have arisen during the course of employment and within the scope of compensable work factors.

5.       Establish Causal Relationship, which means the medical evidence establishes that the diagnosed condition is causally related to the injury or event. This is the most common element of denial!

Rarely cases are approved immediately and most cases when they are denied and the injured worker files additional documentation for reconsideration and appeal, if accepted by OWCP, OWCP  will accept a minimal diagnosis such as sprains, strains or contusions in their acceptance letter. OWCP will deny claims that are filled out by the wrong type of recognized provider at a hospital or urgent care center due to the paperwork being the wrong type of non-accepted OWCP  CA-forms and disregard the diagnosis or findings of the hospital or urgent care doctors due to the fact that the wrong type of paperwork was submitted that is not recognized by OWCP.  When a federal worker appeals with the appropriate OWCP CA-Forms then OWCP will use that  same documentation that they used to deny your case previously to now use to determine your minimal diagnosis of the hospital or urgent care center medical provider to a minimal intake diagnosis of bruises, sprains and strains. This is a common tactic of case workers in OWCP. Often when an Federal  injured worker receives an acceptance letter from OWCP they are so relieved to finally be able to receive treatment or get reimbursed for leave or sick time etc …that they do not notice that the acceptance diagnosis is a very minimal diagnosis and often times is considerably less accurate or definitive to what their actual diagnosis is! Now the important part of understanding of this part is because the denial of claims usually take weeks or months to get approved. The minimally accepted diagnosis also is considered to be resolved within weeks and months. So as soon as you get your acceptance letter …you will quickly get a letter of denial that your condition does not need any further treatment because it should have resolved after these weeks and months. Pretty devious but this tactic is employed all of the time to OWCP claims. 

 I often have to explain to patients that the fight to get your full claim with all of your accurate diagnosis included needs to be continued and submitted. When you the federal worker receive an OWCP acceptance letter an alarm bell should sound off in your head if your acceptance letter only lists minimal diagnosis of bruises and strains. Often times when an intake medical provider sees an orthopedic injury the diagnosis is initially strain, sprain and or pain, swelling or contusion. This is due to the fact that the amount of damage or severity and location of the tearing of muscles, ligaments and tendons has not been confirmed more definitively by x-rays, CAT scans or MRIs. Later on the same day, next day or next weeks these diagnostic tests confirm a more severe diagnosis that is added to the list of diagnosis to the OWCP case  but the case worker ignores this diagnosis and only lists the initial intake diagnosis of the urgent care provider. I always find it interesting that the same urgent care provider who’s paperwork is insufficient to establish an OWCP claim that causes the injured federal worker to receive an initial OWCP denial of their work-related injury claim later is the paperwork they use as the justification for the minimal diagnosis. Then when the proper forms are submitted by your or your medical provider they choose to use the diagnosis portion of the initial  rejected paperwork to minimize an injured worker’s claims. This is a common tactic and injured federal workers need to know their rights, responsibilities and remedies to have their full accurate diagnosis included in their claim. 

Understand that a contusion diagnosis simply says that you suffered bruises to your injured body areas. It is important to understand that bruises are considered a short term problem that resolves quickly in days and weeks. Strains are injuries to muscle and tendons that are as minor as microscopic tears that weaken muscles and tendons but also can be macroscopic tears ( that means large enough to see with your eyes) to the point of full thickness, and/or partial thickness tears that often result in surgery. So, minimal strains typically are considered a short term problem, that will resolve in a short amount of time of weeks or a couple of months. Sprains are injuries to ligaments and joints without dislocation or fracture. Sprains also can result in 25 -50% thickness tears or complete tears that are significant tears that usually are disabling and result in surgery to regain normal use or function of injured areas. 

Most injured federal workers and their medical providers are so exited to receive an acceptance letter that they do not pay a lot of attention to the accepted conditions and are caught off guard when they receive a denial weeks later from the case worker that they are no longer covering benefits for the accepted OWCP case due to a second opinion doctor stating that these minimal diagnosis conditions have resolved or should have resolved. This is a common tactic…let me go through how this denial strategy works…

After an acceptance letter is sent out to the injured federal worker with a minimal diagnosis the OWCP case worker will soon after,,, send another letter to a second opinion doctor. The letter that is sent to the OWCP second opinion doctor is called a Statement of Accepted Facts with questions that include the following:

1.    Do you think that these bruises, and strains have resolved?

2.    Do you think that any continuation of disability, treatment or modified duty should be continued?

3.    Do you think that any further medical care is medically necessary?

I think you get the picture at this point. The second opinion doctor will review the reports that the case worker provides for the second opinion doctor to do a paper review in order determine if these temporary minimal diagnosis are resolved and that further disability or medical care is appropriate. Now, understand often times this is not an actual examination of the patient by the second opinion doctor but a paperwork review. But there are times when the injured federal worker is required to go be examined by the second opinion doctor and the 2nd opinion doctor of course agrees that the condition is resolved and no further care is necessary. 

Especially if the case worker sends minimal amount of medical records and leaves out other reports. Often times the additional diagnostics do not make it to the second opinion doctor and a biased report and opinion is provided without all of the full clinical paperwork for accurate and definitive information review. I personally see this most often when this type of OWCP minimal diagnosis is accepted and the patient’s additional diagnostics and specialist referrals diagnose the patient with a condition that is significant and requires surgery. 

So, what do you do if your are an OWCP accepted federal injury that receives a minimal diagnosis that is not accurate to the severity of your injury. Ok, lets go through the answer to avoid this problem preventing you from receiving appropriate care when needed. Understand first that some people really do have minor injuries. I work in an occupational medicine clinics and we treat minor injuries all of the time that are painful for the first days or a couple of weeks but with pain injections, medications and therapies they get better quickly and only miss a few days or a couple of weeks and rarely need much time to recover. This is a common occurrence. The important thing you the injured federal worker needs to remember is presenting further evidence of how your injury (when it is accurate and appropriate), IS more severe and needs to be expanded from just the minimal  diagnosis that are accepted is vitally important because the OWCP case worker does NOT SEE your injuries and only can SEE YOUR INJURIES by the MEDICAL EVIDENCE that your medical provider submits. 

So, that is step one in attacking this minimally accepted diagnosis issue. You and your medical provider need to take any and all diagnostics, reports, tests, specialist reports etc and submit it to the case worker in the form of a medical narrative detailing the severity of the condition along with providing the supporting medical tests that support the expansion of additional diagnosis. That is an important step but the second part of the requirements for acceptance is where I see most providers faulter in there presentation. It is not enough to upgrade  your diagnosis with a narrative that includes supporting medical evidence tests and diagnostics… you must include a causation statement of how the more severe injuries are causally related to the work-related injury. You must request that your medical provider do a causation statement that explains how the work-related injury is the direct cause of the severe injury and explain the mechanism of injury and causation in the narrative. 

An example of how OWCP will respond to additional medical evidence with out a written statement of causation or a weak causation statement is the following:

Your doctor says your shoulder sprain is actually a rotator cuff tear based on examination and MRI …as a consequence of further diagnostic assessment such as MRIs. The doctor requests that the rotator cuff tear be expanded and included with the shoulder sprain as part of the work related injury. This presentation is never sufficient but is the most common presentation I see from medical providers for injured federal workers. This type of presentation will come back with a denial letter of the 5th element not being met every time. The 5th basic element  is to establish casual relationship, which means the medical evidence establishes that the diagnosed condition is casually related to the injury or event. 

In other words OWCP says, ok…the patient has a more serious injury or condition but how is this caused by the nature of the work-related injury? How is the rotator cuff not a pre-existing condition or how does OWCP know that you actually tore your rotator cuff falling in your garage etc. SEE how this lack of causation statement leaves plenty of opportunities for denying your claim from being fully accepted for all of your  actual injuries. So, pay close attention to your first acceptance letter and make sure if you have a more severe injury you present the medical evidence from an OWCP approved medical provider that contains an expansion diagnosis narrative with supporting diagnostic tests along with a strong causation statement explanation. So, I hope that you have a better  understanding of how to get your claim FULLY accepted instead of minimally accepted. 

Well that does it for this episode of Federal Workers Comp Coffee break  Podcast. 

I want to thank you for listening and want to remind you to share this podcast with other federal workers you think would benefit from this information. Also if you need an approved medical provider for your DOL -OWCP Or FEDERAL Maritime-Longshorman case in Florida you can find me in Tampa at two different locations and in Jacksonville. To make a consult with me to discuss your case  or if you know someone in Florida who is recently injured or has an older case that is receiving a lot of denials, you can email or  call my clinic at 813-877-6900. Also, if you are in another state and you want me to assist you with any claim questions or assistance for your doctor you can email me at 

fedcompconsultans@protonmail.com. I do this for free as a service to you. I know that I can not be everywhere…and sometimes YOU need to teach this stuff to YOUR doctor. 

 Find me on twitter at @FedCompPodcast. Drop me a message there as well.  See you next time.