WORKERS COMPENSATION CITUS ET CERTUS. Ms. Kappler 435 MSS/DPCS-A

Transcription

1 WORKERS COMPENSATION Ms. Kappler 435 MSS/DPCS-A

2 References Definition of FECA Responsibilities under FECA Requirements of Coverage Electronic Data Interchange (EDI) System Questions OVERVIEW

3 REFERENCES Title 5, USC (FECA Law) Title 20, CFR, Chap 1, Subchapter A, Part 1, and Subchapter B, Parts 10 and 25 DoD Directive Subchapter 810 CA-810 Handbook (OWCP publication)

4 What is FECA? The Federal Employees Compensation Act (FECA) provides compensation benefits to Federal civilian employees for work-related injuries or illnesses. It is the exclusive remedy for Federal employees for work-related injuries or death. The law is non-adversarial in nature and remedial in intent. The FECA is administered by the Department of Labor, Office of Workers Compensation Programs (OWCP). The 12 OWCP district offices adjudicate the claims and pay the benefits, and the costs of those benefits are charged back to the employing agency

5 RESPONSIBILTIES UNDER FECA Three parties involved in processing a claim under FECA OWCP (Office of Worker s Compensation Programs) Employing Agency (Supervisor and Injury Compensation Program Administrator [ICPA]) Employee

6 Has the burden of proof to establish a claim EMPLOYEE Has to submit factual evidence as required by OWCP Has to provide objective medical evidence to support the level of benefits claimed Must keep both the agency and OWCP advised of his or her status and submit reports as required Must seek and accept suitable work when such work is available

7 SUPERVISOR Enforce safety regulations Advise employees of his/her responsibilities in filing a claim, rights, and benefits (CA-10) Complete claim forms in a timely manner, verify accuracy, and provide all required information Forward all claims promptly to the ICPA Continue pay in traumatic injury claims as appropriate and promptly authorize medical care within regulatory guidelines Assist employees in returning to work by providing work within the employee s work tolerance limitations Represent agency interests in monitoring claims

8 REQUIREMENTS OF COVERAGE

9 REQUIREMENTS OF COVERAGE Every claim submitted must satisfy five elements in order to establish entitlement to FECA benefits: Timely filed Federal employee Fact of injury (factual and medical) Performance of duty Causal relationship

10 TIMELY FILED Traumatic injury: Three years from the date of injury (DOI) Occupational: Three years from the date of last exposure or date employee becomes aware of medical condition and its relationship to employment factors

11 FEDERAL EMPLOYEE Any civil employee in any branch of the Federal government Volunteers performing personal services Excludes independent contractors in most instances Contractors can be considered Federal employees for FECA purposes under certain conditions

12 FACT OF INJURY FACTUAL: Actual occurrence of an accident, incident, or exposure at the time, place and in the manner alleged - Employee statements - Witness statements - Mishap reports - Investigative reports MEDICAL: Whether the medical evidence supports that an employee has a diagnosed condition Initial treatment notes X-rays Diagnostic tests

13 CAUSAL RELATIONSHIP Based entirely on medical evidence provided by physicians who have examined or treated the employee Direct Cause Example: Office clerk trips on a carpet, falls and injures a knee while walking to the copier to make copies of a report requested by the supervisor Aggravation: a pre-existing condition is worsened by a work related injury Temporary Permanent

14 Electronic Data Interchange (EDI) It has been DoD policy since July 2003 to utilize EDI when submitting claims DOL will be monitoring agency timeliness for claim submission as a result of SHARE Defense Safety Oversight Council (DSOC) will be monitoring DoD agency timeliness and use of EDI for claim submission Claims filed utilizing EDI are electronically transmitted to OWCP from the agency Any delay due to internal routing of paper claims and mailing forms to OWCP are eliminated

15 EDI INFORMATION FLOW Employee reports the injury to his/her supervisor Process is started by accessing the EDI website Supervisor and employee complete the electronic form, which is transmitted to the ICPA. Supervisors do not need any special access to file the claim electronically, only a computer with internet access

16 EDI FORMS The forms can be accessed at the URL The EDI forms are patterned directly on the hard copy forms CA-1 and CA-2. Therefore, the basic instructions for completing the forms are the same as with paper

17 QUESTIONS?

18 Injury Compensation DESK GUIDE

19 Overview Types of Injuries Benefits under FECA How to submit a claim through the system

20 TYPES OF INJURIES Traumatic Injury (CA-1) Authorization for Treatment (CA-16) Duty Status Report (CA-17) Occupational Disease (CA-2) Claim for Compensation (CA-7) Attending Physician s Report (CA-20)

21 TRAUMATIC INJURY (CA-1) A wound or other condition of the body caused by external force, including stress or strain. The injury must be identifiable as to time and place of occurrence and member or function of the body affected. It must be caused by a specific event or incident or series of events or incidents occurring within a single day or work shift.

22 TRAUMATIC INJURY (CA-1) Issue CA-16 within 48 hours following first examination or treatment; form is not used with a CA-2 Used to authorize treatment in traumatic injury cases Authorized treatment and non-invasive procedures for a period of up to 60 days Covers referral from one provider to another

23 CA-1 NOTICE OF TRAUMATIC INJURY For lost time or medical expense claims, receipt by OWCP within 10 working days from Date of Notice is a regulatory requirement Can be filled out and signed for the employee if they are incapacitated Form should be sent to the appropriate OWCP district office Only for traumatic injuries there is the option to get continuation of pay (COP) if there is lost time, so it won t be charged against the employee s annual or sick leave

24 CA-16 AUTHORITY FOR EXAM AND/OR TREATMENT Employee has right to choose treating physician Should be issued even for questionable claims Treatment by chiropractor is covered under only one circumstance (subluxation)

25 CA-17 DUTY STATUS REPORT Used to monitor extent of disability and COP entitlement Used to inform treating physician about available light duty or the physical requirements of the employee s DOI job

26 OCCUPATIONAL DISEASE (CA-2) A condition which is produced by continued or repeated exposure to elements of the work environment such as noxious substances, damaging noise levels, or repetitive work activities/movements occurring over a period of more than one work day or shift.

27 OCCUPATIONAL DISEASE (CA-2) Claim must be accepted in order for OWCP to pay benefits Employee is responsible for all medical costs and time off until claim is accepted Employee is not eligible for Continuation of Pay (COP) Agencies will not issue a CA-16

28 Medical Benefits Monetary Benefits Death Benefits Continuation of Pay Claim for Compensation BENEFITS UNDER FECA

29 MEDICAL BENEFITS

30 MEDICAL BENEFITS TREATMENT Physician Hospital Physical Therapy Surgery Diagnostic Testing (Pre-approval Forms are available on the Department of Labor homepage Civilians do not pay the military facility for the first visit if they are there for an on-the-job injury. The doctor completes the CA-16, and the employee shows the cashier the CA-1 and the CA-16 forms

31 MEDICAL BENEFITS Pre-approved Surgery Physical Therapy Tests (Pre-approval Forms are available on the Department of Labor homepage Civilians do not pay the military facility for the first visit if they are there for an on-the-job injury. The doctor completes the CA-16, and the employee shows the cashier the CA-1 and the CA-16 forms.

32 Medical Treatment Items Unique Overseas Because we are overseas, certain aspects of FECA law do not protect US citizens who choose to obtain services from a German doctor, hospital or pharmacy. Employees must pay for all costs incurred by a German facility. Unpaid bills are subject to liquidation procedures. Submit the paid receipts with the OWCP forms. Encourage your employees to pay the bill; they will be reimbursed by OWCP. Forms must be filled out in English and submitted to OWCP. It is the responsibility of the employee to ensure the medical statements and forms have an English translation. Nontranslated bills and forms take longer to process.

33 MEDICAL BENEFITS EQUIPMENT Prosthetic Medical Hardware (i.e. wheelchair, crutches, braces, etc.) Housing Modification Vehicle Modifications

34 MEDICAL BENEFITS MEDICATION Prescriptions required as a result of the accepted condition are covered No monetary cap Prescriptions are covered as long as their need is medically supported

35 WAGE LOSS MONETARY Must be in a LWOP status Provided at 66 2/3 % without dependents or 75% with dependents Tax Free Lasts as long as medical documentation supports disability - no time limit FEHB and FEGLI deductions are made by OWCP

36 SCHEDULED AWARD MONETARY Paid for loss or loss of use of certain members/functions of the body Claimant can be working and collect Scheduled Award Paid at the same rate as compensation (66 2/3% or 75%) Award is stated in weeks of compensation not in a specific amount of money Cannot be paid for impairment of back, heart or brain Claimant files for Scheduled Award using CA-7 form

37 DEATH BENEFITS Payable when claimant s death is causally related to the accepted condition Death is reported on CA-6 form by the Employing Agency Survivors submit claim for death benefits on form CA-5 or CA-5b depending upon relationship to decedent

38 CONTINUATION OF PAY (COP)

39 CONTINUATION OF PAY COP is the continuation of an employee s regular pay by the employing agency with no charge to sick or annual leave It is only given in traumatic injury cases and is given for a maximum of 45 calendar days per injury Entitled only to the time necessary to obtain treatment Each day with a period charged to COP will be counted as one day of COP entitlement Weekend days and holidays occurring during a period of disability will be counted toward COP entitlement OWCP is the final authority on COP

40 CONTINUATION OF PAY IS PAYABLE WHEN An employee is out of work as a result of Medical treatment Disability An employee returns to work with a wage loss (i.e. loss of shift differential) An employee is formally reassigned to another position with a lower rate of pay

41 Employee responsibilities CONTINUATION OF PAY File CA-1 form within 30 days of the date of injury Provide supporting medical documentation within 10 calendar days from the date the COP is claimed or the date disability began (whichever is later) Accept suitable light duty work when available and offered by the employing agency Keep supervisor informed of any changes in work status

42 CLAIM FOR COMPENSATION CA-7 (Claim for Compensation on Account of Traumatic Injury or Occupational Disease) is used to claim compensation for wages or time lost due to a traumatic injury (if not eligible for COP or over the max COP days) or occupational disease. Always attach a CA-20 (Attending Physician s Report) to a CA-7 for medical documentation. In order to be eligible for compensation, employee must be in a non-pay status. Compensation is based on the employee s weekly pay at the time of injury (that s why it is important to put the salary an the forms)

43 EDI On the next pages you will see the process on how to submit a claim through EDI.

44 After entering the URL for the Supervisor portion of EDI, this screen will open. The user will need to read and select OK in order to continue.

45 When the initial claim entry screen appears, the employee s SSN and DOB will be entered and type of claim form will be selected.

46 Once the employee s information is added, select the Enter claim button to begin entering data.

47 The form will now open with the employee s information populated into the appropriate fields using data from the personnel system

48 White fields are required to be filled in Yellow fields are optional and do not have to be filled in Gray fields are informational and cannot have data entered into them

49 Some fields require the data entered to be in a particular format. For example, phone numbers should be entered without using any () or -

50 If data is entered into a field using the wrong format, the application will not let the user move forward until the data is correctly entered. A message will be provided at the bottom of the screen to inform the user as to what needs to be done to fix the format problem

51 A message will also be displayed at the bottom of the screen when a dropdown box is available for a field. Fields with Zip Codes have this function. To activate the box, place the cursor in the field and hold down the CTRL and L keys at the same time

52 A box will appear that allows the available entries in that field to be searched

53 Entering FA (Foreign address) before the %

54 The employee s information will be entered into the system. Pay particular attention to fields that require a date and time such as Block 10. If no time is entered in the block, the time will default to 12:00 a.m.

55 The employee then elects whether to use Continuation of Pay and enters the date that the claim is being entered into the EDI application

56 Enter a witness statement in this space. The witness will sign the statement when the claim form is printed. If there is no statement, leave this space blank. If the statement will not fit into the space annotate witness statement forwarded under separate cover in this space and fill out the witness information. Send the separate signed witness statement to the ICPA.

57 Enter the required information in the appropriate fields. Paying attention to the format for data entry. (No military time)

58 If the supervisor does not believe the employee was injured in performance of duty, no should be checked and the facts that support that position should be provided. Otherwise leave the box checked yes. If the information will not fit into this box, annotate additional information forwarded under separate cover and send the information to the ICPA to forward to OWCP. If the supervisor believes that willful misconduct was involved, yes should be checked and the facts that support this position provided. Otherwise leave the box checked no If the information will not fit into this box annotate additional information forwarded under separate cover and send the information to the ICPA to forward to OWCP.

59 Example of a third party claims would be an automobile accident in which the other driver was found to be at fault If the individual was treated at an agency facility the information in Block 32 must be provided (unique to EDI/SAFER)

60 If, in the investigation of the claim, nothing contradicting the employee or witness is uncovered, it would be appropriate to answer yes. The supervisor does not have to witness the alleged incident to answer yes. If an investigation has been started, but the results are not available at the time of claim filing, then annotate investigation in progress, results forwarded under separate cover. The ICPA should be provided with a copy of the results to forward to OWCP

61 If the agency wishes to challenge the claim, then no must be selected for this item and the reasons for the challenge entered into this space. If the information will not fit, then annotate additional information will be forwarded under separate cover and forward the information to the ICPA

62 Enter the reason for the controversion of COP in this space.

63 Check all that apply for the sections on this tab. This information will be used to generate the OSHA 301 notice used for safety notification (Unique to EDI/SAFER) and will not be sent to OWCP

64 Using CTRL+L when the cursor is placed in the Privacy Case Status field will display the listing of values for that field

65 If an on-site investigation was performed then a root cause will have to be entered The supervisor s address should be entered in this field. This will allow the supervisor to receive a copy of the OSHA 301 notice generated by the system

66 Verify the address

67 Select the appropriate filing instructions

68 Select the View Claim button

69 Once the View Claim button is selected, a dialog box will open providing two options

70 The View Claim for Printing and Submit to ICPA option allows the claim to be viewed and printed as a.pdf file and then sent to the ICPA without any further action by the user The View Draft Copy of Claim to Verify Data option allows the claim to be viewed and printed as a.pdf file but the user must then select the Submit Claim button to send the claim to the ICPA

71 Review the claim. If the information is correct, select the print icon and print the claim. The employee, supervisor, and witness should then sign their portion. The signed copy is forwarded to the ICPA for record retention

72 If the View Draft Copy of Claim to Verify Data option was selected, the Submit Claim button must be selected on order to transmit the claim to the ICPA