Second Opinion/ Independent Medical Examinations (IME) Carol Gavero ICUC San Francisco District Management Advisor

Transcription

1 Second Opinion/ Independent Medical Examinations (IME) Carol Gavero ICUC San Francisco District Management Advisor

2 Objectives Discuss OWCP Directed Medical Examinations When Second Opinions/IME s (Independent Medical Examination) are considered The Claims Examiner s Process of Referral in referring claimant s to OWCP directed examination (2)

3 Definitions SECOP Second Opinion. Opinion will be requested by OWCP from a physician who specializes in the field of medicine pertinent to the issue when medical issues that arise cannot be resolved on the basis of opinions given by the attending physician and the DMA. DMA District Medical Advisor. Each district office has one or more physicians on staff or under contract who respond to question raised by OWCP. These physicians interpret medical issues posed by treating physicians and provide their own opinion on medical questions. IME Impartial Medical Examination. Also known as a Referee is arranged when a conflict of medical opinion occurs in a case when the file contains differing medical opinions of approximately equal weight. (3)

4 District Medical Advisor Services District Medical Advisors (DMAs) are physicians hired by OWCP whose role is to act as a consultant on medical issues. The DMA does not see or examine the injured worker. They provide claims examiners (CE) with medical opinions based on a review of the Statement of Accepted Facts (SOAF) and the medical records. The functions of the DMA include: interpretation of medical reports; rendering medical evaluations in his or her own right; providing guidance or instruction to claims staff regarding general medical issues, etc. (4)

5 Consulting with a DMA Schedule award cases must be sent to a DMA for a final permanent impairment rating for a schedule award. Certain types of surgery require DMA review, including an organ transplant, spinal surgery or a total knee arthroplasty. Other destructive procedures, such as chordotomy, rhizotomy and amputation must also be referred to the DMA. (5)

6 OWCP Directed Medical Exams The FECA (5 U.S.C. 8123(a)) provides that: An employee shall submit to examination by a medical officer of the United States or by a physician designated or approved by the Secretary of Labor, after the injury and as frequently and at the times and places as may be reasonably required. The FECA (5 U.S.C. 8123(d)) provides that: If an employee refuses to submit to or obstructs to an examination, his right to compensation under this subchapter is suspended until the refusal or obstruction stops. Compensation is not payable while a refusal or obstruction continues, and the period of the refusal or obstruction is deducted from the period for which compensation is payable to the employee. (6)

7 Second Opinion (SECOP) Examinations OWCP can seek a second opinion from an independent physician who is a specialist specific to the issue and medical condition at issue (e.g. orthopedic specialist for bone and soft tissue injuries, cardiologists for heart problems). The physician is selected by a medical referral group that has been contracted by OWCP to provide second opinion medical referrals. The decision to refer a case for a second opinion examination rests with the CE, though such an exam may be recommended by a Field Nurse (FN), DMA, or the employing agency. (7)

8 When is a SECOP considered? When there is enough evidence from the attending physician(ap) to suggest that the claimant might be entitled to benefits, but OWCP still does not have enough evidence to accept the case. When the AP s examinations and reports in occupational disease cases do not provide the specific evidence that OWCP requires for adjudication. When temporary total disability (TTD) has gone on longer than usual in a case, and the AP is not an appropriate specialist or has not satisfactorily explained the reason for the continued disability. (8)

9 When is a SECOP considered? OWCP has reason to believe that a claimant is no longer disabled due to the accepted work injury, but the AP still supports TTD. When the claimant appears to have reached maximum medical improvement (MMI) but the claimant s AP cannot, or will not, send an acceptable permanent impairment evaluation based on the current AMA Guide. When the DMA has been asked for an opinion and he/she responds that additional information is needed before he/she can make a judgment or provide a rating of impairment. (9)

10 Referee/Impartial Medical Examination (IME) The FECA (5 U.S.C. 8123(a)) and 20 CFR of the implementing regulations state "if there is a disagreement between the physician making the examination for the United States and the physician of the employee, the Secretary shall appoint a third physician who shall make an examination. The selection of a physician who is an appropriate specialist and who has had no prior connection with the case is made by OWCP on a strict rotational basis. (10)

11 When Referee/IME s are considered A referee medical specialist s examination is sought when: There is a conflict of opinion between the attending physician and the second opinion specialist, The conflict will affect decisions about paying, reducing, or terminating benefits, and Both of the conflicting opinions appear to be medically well-reasoned, based on an accurate and complete history and facts, and are found to be of approximately equal weight. (11)

12 Second Opinion and Referee Exams Claimant s Rights and Obligations The FECA (5 U.S.C. 8123) provides: The claimant has the right to have a physician present during a second opinion examination (paid by the claimant). However, the claimant does not have that same right during a referee examination, unless OWCP concludes that exceptional circumstances exist. The employee is not entitled to have anyone one else present unless a need is established and OWCP approves (e.g. interpreter). The employee must attend the examination and benefits may be suspended for failure to report for examination. The claimant is entitled to travel expenses incurred. If the claimant misses work to attend the examination, they are entitled to compensation for lost wages at 100%. (12)

13 Obstructing an Examination What are the penalties for failing to report for or obstructing a second opinion or referee examination? (a) If an employee refuses to submit to or in any way obstructs an examination required by OWCP, including testing such as functional capacity determinations conducted in connection with an OWCPdirected medical examination, his or her right to compensation under the FECA is suspended under 5 U.S.C. 8123(d) until such refusal or obstruction stops. The action of the employee's representative is considered to be the action of the employee for purposes of this section. The employee will forfeit compensation otherwise paid or payable under the FECA for the period of the refusal or obstruction, and any compensation already paid for that period will be declared an overpayment and will be subject to recovery pursuant to 5 U.S.C (13)

14 Obstructing Exams (Con t) b) If the employee does not report for an OWCP-directed examination or in any way obstructs this examination, he or she may provide an explanation to OWCP within 14 days. If this explanation does not establish good cause for the employee's actions, entitlement to compensation will be suspended in accordance with 5 U.S.C. 8123(d). Should the employee subsequently agree to attend the examination or cease the obstruction (as expressed in writing or by telephone documented on Form CA-110), OWCP will restore any periodic benefits to which the employee is entitled when the employee actually reports for and cooperates with the examination. Payment is retroactive to the date the employee agreed to attend or cease obstruction of the examination. (14)

15 Process of Scheduling Exams Claims Examiner (CE) prepares a Statement of Accepted Facts (SOAF) The SOAF is one of the most important documents a Claims Examiner (CE) prepares. It is the written summary of the CE's findings of facts. It serves as a factual frame of reference for the medical specialist, the CE or other case reviewer. When it is used by physicians who base their medical opinions solely on the information presented in the SOAF, the outcome of a claim may depend on its completeness and accuracy. Therefore, the SOAF must clearly and accurately address the relevant information. CE will include along with the SOAF, a list of questions to the Second Opinion/IME doctor. A list of pertinent questions or issues to be addressed; diagnosis, continuing residuals, work capabilities, etc. (15)

16 Statement of Accepted Facts For a physician to form a general impression of the individual or evidence to be evaluated, the CE must provide the following information in the SOAF: Date of Injury Claimant's Date of Birth Job Held on Date of Injury Name of Employing Agency Employment history Mechanism of Injury Condition(s) Claimed or Accepted (16)

17 SOAF (Example) STATEMENT OF ACCEPTED FACTS IN THE CASE OF JAMES JONES FILE NUMBER: xxxxxxxxx James Jones, date of birth 03/22/1975, is employed as a maintenance worker with the Department of Veterans Affairs. On April 14, 2009, he sustained an injury when a desk he was moving slid off a fork lift and slammed into his left knee, pinning his knee between the desk and a wall. He received initial medical attention at the Northwestern Medical Center on April 14, The conditions of a left knee contusion and left knee sprain are accepted as causally related to the April 14, 2009 employment injury. A left knee arthroscopy was performed on September 10, Mr. Jones has not returned to work to date. (17)

18 SOAF (Example) The duties of a maintenance worker require walking and standing for up to six hours per day; intermittent squatting, bending and kneeling for up two hours per day; pushing/pulling up to one hour per day; climbing stairs 4½ hour per day; and occasional lifting up to 50 lbs. Prior medical history: Claimant suffered a torn left knee medial meniscus as a result of a soccer injury at age 16. (18)

19 Example of some questions to physician File Number: SECOP-O-SE QUESTIONS FOR THE SECOND OPINION EXAMINATION PHYSICIAN Describe both the objective and subjective findings from physical examination. Do the subjective complaints correspond with the objective finding? Discuss the result of any diagnostic testing performed (19)

20 Example of some questions to physician List all current diagnosis causally connect to the work injury. Has the work-related condition resolved? If not, is there evidence to support that the work related condition(s) is still active and causing objective findings. Provide a clear rationalized explanation including specific findings from your examination/evaluation. If the work related condition(s) has not resolved, please explain. Has the claimant reached maximum medical improvement? (20)

21 Example of some questions to physician Discuss the prognosis and whether there is a need for any further treatment. Provide basis for your opinion and outline any treatment recommendations. Based on clinical presentations, is this claimant back to the date of injury status as follows: clerical/admin duties; change positions as needed, avoid lifting, pushing/pulling using the left arm; able to type using both arms. Please explain the basis of your opinion. Is this claimant unable to return to date of injury modified nursing assistant job, are work restrictions/limitations medically warranted? If the present level of disability a direct result of the accepted work-related condition? Please explain the basis for your opinion and completed OWCP-5. (21)

22 CE Referral Process CE must also gather all the medical evidence to be reviewed by the Second Opinion/IME doctors. For unadjudicated cases, all medical reports; For medical management, disability management or surgery referrals in cases that are within three years of acceptance: a. All operative reports; b. All diagnostic tests and c. All medical records from any qualified physician + (22)

23 CE Referral Process CE gives 30 days from the date of examination for the submission of the medical report. If needed for a second opinion, the CE will send a copy of the report to the claimant s treating physician for comments. The CE allows 30 days for the treating physician to respond before the CE will take next action. (23)

24 Scenario Mr. Smith, 61 years old, Shipfitter was injured on 7/24/1990. His case is accepted for plantar fasciitis and heel spur. The claimant s current case status is PW. He continues to submit medical reports annually. Should he be referred to a second opinion examination? (24)

25 References DFEC 5 U.S.C (a)(d) Injury Compensation for Federal Employees Publication CA CA-810.pdf Injury Compensation Training Modules (25)