DOL - OWCP Emergency Medical Care, Ca-16 & Optum PBM

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.

Form CA-16, Authorization for Examination and/or Treatment. Form CA-16 is the vehicle by which the employing agency authorizes initial examination and/or medical treatment at OWCP expense. It is used to refer an employee who sustains a traumatic injury to a local physician or hospital of the employee's choice.  CA-16s are issued by Employing Agencies to Injured Workers so they can seek immediate medical care. When there is a CA-16, NO authorization is needed for office visits and consultations, labs, hospital services (including inpatient), X-rays (including MRI and CT scan), physical therapy, and Emergency services (including surgery) related to the work injury. 

a. Emergency Medical Facility. Emergency medical care by private physicians, clinics or hospitals may be authorized if such care is warranted. The employee may seek continuing medical care from the physician who provided the initial treatment or select another local physician.
(2) Effect of Adjudication. Once a case is accepted, the period of authorization is automatically extended to cover necessary services for the accepted condition, and additional authorization is not necessary unless requested by a provider in a specific case.

The U.S. Department of Labor (DOL) has contracted with Optum Workers’ Compensation Services (“Optum”) to provide Pharmacy Benefit Management (PBM) services to the Federal Employees’ Compensation Act (FECA) Program. Optum will be responsible for pharmaceutical transactions including but not limited to implementation of FECA Program eligibility determinations and pricing for pharmaceutical drugs provided to FECA claimants. FECA claimants MUST use the Optum/FECA pharmacy benefit card for injury-related prescriptions. No other pharmacy benefit card will be recognized for a claimant’s federal workers’ compensation injury. In a new Injury Ca-16  without an Optum pharmacy card the injured worker will need to pay for their medications with their personal insurance while a new case is being adjudicated.

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 Mi

Transcript

Form CA-16, Authorization for Examination and/or Treatment. Form CA-16 is the vehicle by which the employing agency authorizes initial examination and/or medical treatment at OWCP expense. It is used to refer an employee who sustains a traumatic injury to a local physician or hospital of the employee's choice. The employer may not authorize examination or medical treatment in any case that OWCP has disallowed.

 a. Traumatic Injury.

 (1) Period of Authorization. Form CA-16 authorizes treatment for 60 days from the date of injury, unless OWCP terminates the authorization sooner. The Office has a contractual obligation to pay for medical services and instructs physicians to contact the district office for extension of that period. K.D., Docket No. 11-16 (issued August 16, 2011) [While the chiropractor's report was insufficient to establish that the May 5, 2010 MVA caused or aggravated a diagnosed medical condition, the Form CA-16 authorization from the employing establishment created a contractual obligation to pay for the cost of necessary medical treatment until OWCP terminated the authorization of medical treatment on June 21, 2010.]

 (2) Effect of Adjudication. Once a case is accepted, the period of authorization is automatically extended to cover necessary services for the accepted condition, and additional authorization is not necessary unless requested by a provider in a specific case. If a case is denied, however, authorization for further treatment must be revoked even though 60 days have not elapsed.

 (3) Emergency Circumstances. Form CA-16 may be used to authorize treatment in cases of a doubtful nature, and in emergencies or unusual circumstances by completing Form CA-16 and checking block 6B of the form.

 OWCP may approve payment for medical expenses incurred even if Form CA-16 has not been issued and the claim is subsequently denied. Payment in situations meeting these criteria must be determined on a case-by-case basis (see Val D. Wynn, Docket No. 88-1813, issued March 10, 1989). D.P., Docket No. 11-50 (issued October 26, 2011)

 (ECAB held that although there was insufficient rationalized medical evidence to establish appellant's claim of injury, OWCP failed to consider whether emergency or otherwise unusual circumstances were present such that reimbursement of medical expenses would be appropriate even though a CA-16 had not been issued in this case.)

 CA-16s are issued by Employing Agencies to Injured Workers so they can seek immediate medical care. When there is a CA-16, NO authorization is needed for office visits and consultations, labs, hospital services (including inpatient), X-rays (including MRI and CT scan), physical therapy, and Emergency services (including surgery) related to the work injury. 

a. Emergency Medical Facility. Emergency medical care by private physicians, clinics or hospitals may be authorized if such care is warranted. The employee may seek continuing medical care from the physician who provided the initial treatment or select another local physician.

 b. Employing Agency Health Units. These facilities are equipped to provide immediate assistance and/or to refer employees to local physicians or emergency care facilities. When indicated, rescue squads or similarly trained and equipped units may be used to move injured persons.

 The U.S. Department of Labor (DOL) has contracted with PMSI, LLC d.b.a Optum Workers’ Compensation Services of Florida (“Optum”) to provide Pharmacy Benefit Management (PBM) services to the Federal Employees’ Compensation Act (FECA) Program. Optum will be responsible for pharmaceutical transactions including but not limited to implementation of FECA Program eligibility determinations and pricing for pharmaceutical drugs provided to FECA claimants. Optum can also manage scheduling and delivery of durable medical equipment, medical supplies, and diagnostic services for a claimant’s work-related injury.

FECA claimants MUST use the Optum/FECA pharmacy benefit card for injury-related prescriptions. No other pharmacy benefit card will be recognized for a claimant’s federal workers’ compensation injury. Use of the Optum/FECA pharmacy program and a network pharmacy is mandatory; otherwise, payment of medications for a FECA related injury will not be authorized at the pharmacy. You can not access the OPTUM/FECA pharmacy benefit ECOMP system until you have a OWCP case # and will not received a permanent OPTUM card to replace your temporary card until you receive approval of your OWCP case through acceptance of your injured workers claim adjudication. So you will have to use your personal insurance to receive medications if your case is pending development and you do not have an accepted OWCP claim or you only have a CA-16. 

I hope this clears up the confusion that CA-16 and temporary optum cards presents in new OWCP claims. I get a lot of emails on this one and there are a lot of complaints about this OPTUM pharmacy benefit manager system and new injuries and CA-16s. 
Tampa OWCP Doctor