Transcript MANAGING THE PAPERWORK Yvette Talley and Mark Baumann

MANAGING THE PAPERWORK
Yvette Talley
and
Mark Baumann
OBJECTIVES
 Identify the forms required for filing an injury or
illness
 Discuss the appropriate responses on the supervisor
portion of the claim form
 Discuss the importance of communication with the
Workers’ Compensation Staff
 Identify documents used to authorize medical
treatment and duty status reports
ENTITLEMENTS
 Right to file a CA-1 (injury) and CA-2 (illness), to apply
for compensation
 Entitlement includes the option to receive medical
treatment by either the VA Occupational Health Unit
or their primary care provider
 Authorized to designate representation
DEFINITIONS
 FECA- Federal Employees’ Compensation Act
 OWCP-Office of Workers’ Compensation Programs
 Employer or Agency - refers to officers and employees
of an employer having responsibility for the
supervision, direction and control of employees
 Representative-An individual or law firm properly
authorized by a claimant in writing to act for the
claimant in connection with a claim
CA-1, Notice of Traumatic Injury
and Claim for Continuation of
Pay/Compensation
CA-1 (cont)
 Employee must give notice in writing using form CA-1
 Review page one of the form ensuring it includes a
detailed description of the injury
 Complete and sign page two of the form within 2-3
days
 Complete Receipt of Notice attached to CA1 and
provide to employee
CA-1 (cont)
 Submit completed form to Workers’ Compensation
Office
 Medical care authorized if appropriate
 Advise the employee if COP will be controverted
 Advise the employee of their responsibility to submit
Prima Facie medical evidence of disability within 10
calendar days
Additional Forms Completed
With the CA-1
 Release of Information
 Election of Physician
 First Script Card
 Employee Responsibilities
 10.330
Sample Release of Information Form
I hereby authorize release of medical information related to my claim for workers’ compensation
benefits relating to my injury/illness of _________________________________________,
which occurred on ____________(date)_____________. Please provide medical information
concerning my injury/illness to the address/office below to be used in processing my claim for
benefits under the Federal Employees’ Compensation Act (FECA).
Signature: ____________________________________ Date: _________________________
Name: _________________________________ Date of Birth: ________________________
SSN: (last 4) ___________
Please return requested information to:
Workers’ Compensation Staff
VA Medical Center
123 NE Main St.
City, State, Zip
Fax: ___________________
If additional information is needed, please call: ____________________________________
Sample Election of Physician Form
Name: _________________________________ Date of Injury: ________________________
I have read and understand the Employee Bill of Rights provided in the Automated Safety
Incident Surveillance and Tracking System (ASISTS) in conjunction with completion of Form
CA-1/CA-2 for this injury. I understand I have the right to choose my initial choice of physician
to provide my medical care/treatment for the above injury.
_______Occupational Health Unit, VA Medical Center
_______Private Physician:
Name: _______________________________________
Medical Facility: _______________________________
Address: _____________________________________
City, State and Zip: _____________________________
Phone: (____)_____________ Fax: (____) _________
First appointment scheduled for __________________(date) at __________________(time).
Chiropractic services are limited to specific treatment(s) to correct a spinal subluxation as
demonstrated/diagnosed by X-ray to exist.
______I decline any medical care/treatment at this time. I understand this may affect future
authorization for medical benefits in relation to this injury/condition.
______Employees should request any change in treating physician in writing to the U.S.
Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP), and
explain the reason for the request.
Employee Signature: ______________________________ Date: _____________________
Print Name: ________________________________________________________________
Forward this signed original to the Workers’ Compensation Program staff for filing in the
case file.
Employee Responsibilities – Traumatic Injury
The Federal Workers' Compensation Program is a benefit for Federal Employees. It is your responsibility
to stay actively involved in every facet of the program.
Follow time and leave policy by requesting leave from your supervisor for all injury related absences.
Keep your supervisor and this office informed of all injury related lost time and restrictions. Provide a
return to work statement indicating your current work status to your supervisor and this office following
each medical appointment. If you are given any work restrictions make sure they are specific, if the
restrictions are not specific you will be requested to obtain clarification from your physician.
In order to receive Continuation of Pay (COP) for injury related absences you must provide our office
supporting medical documentation from your physician. If we do not receive supporting medical
documentation COP will not be authorized. Eligibility for receipt of COP is for a period of up to 45 days.
Following the period of COP eligibility you may claim compensation for injury related lost time from work
by completing form CA-7, Claim for Compensation. To avoid an interruption of pay for disability
th
extending beyond the COP period please contact our office by the 30 day of disability to obtain form
CA7 and instruction for completion of the form.
Provide our office a copy of the medical note for all treatment received for your injury. Keep us informed
of all appointments and any tests that the doctor has scheduled. Be advised Chiropractor care is limited
to specific treatment(s) to correct a spinal subluxation as demonstrated/diagnosed by x-ray to exist.
Make sure that your physician of choice accepts Federal workers’ compensation and is enrolled with
ACS, Department of Labor’s bill payment and medical authorization program. This also pertains to
pharmacies, physical therapy and durable medical equipment.
Advise your physician that your employing agency will accommodate work restrictions by providing a
limited duty assignment. Department of Labor regulations provide employees must seek work and any
employee who refuses to seek or accept suitable work will not be entitled to compensation.
All medical reports must be signed by a physician. A physician's assistant, nurse or nurse practitioner are
not considered physicians and must be co-signed by a physician. Please be advised the medical
evidence submitted from your physician must have a clear diagnosis and pain is considered to be only a
symptom and not a diagnosis.
If your doctor indicates that you require surgery, notify us immediately. It is the responsibility of the
doctor's office to request authorization for the surgery through ACS. Once your surgery has been
scheduled contact our office regarding your leave options and instruction for claiming compensation for
lost time from work.
I have received my First Script benefit card.
I have received a copy of What are the Requirements for Medical Reports.
If you have additional questions or concerns please contact our office at 123-456-7890.
I have received a copy of this employee responsibility form:
Signature_______________________________________________ Date ___________________
Printed Name ___________________________________________
Medical Reports
Sec. 10.330 What are the requirements for medical reports?
In all cases reported to OWCP, a medical report from the attending
physician is required. This report should include:
(a) Dates of examination and treatment;
(b) History given by the employee;
(c) Physical findings;
(d) Results of diagnostic tests;
(e) Diagnosis;
(f) Course of treatment;
(g) A description of any other conditions found but not due to the claimed
injury;
(h) The treatment given or recommended for the claimed injury;
(i) The physician's opinion, with medical reasons, as to causal
relationship between the diagnosed condition(s) and the factors or
conditions of the employment;
(j) The extent of disability affecting the employee's ability to work due to
the injury;
(k) The prognosis for recovery; and
(l) All other material findings.
The report may be made in narrative form on the physician's
letterhead/stationery. This report, and any other medical report, work
statement and/or disability for work statement must be signed (or
counter-signed) by a qualified physician.
NOTE: Employees are responsible for advising their physician that limited
duty can and will be made available within _____________VA Medical
Center based on the physician’s specific recommendations. It is the policy
of ___________VA Medical Center that all injured employees will be
accommodated unless totally disabled for any and all work. Duties need
not be within or associated with the employee’s current position.
CA-2, Notice of Occupational
Disease and Claim for
Compensation
CA-2 (cont)
 Review page one of the form ensuring it includes a
detailed description of condition and relationship to
employment
 Complete and sign page two of the form within 2-3
days
 Complete Receipt of Notice attached to CA2 and
provide to employee
 Submit completed form to Workers’ Compensation
Office
CA-35, Evidence Required in
Support of a Claim for
Occupational Disease
CA-35 Checklists
 Occupational Disease (generic)
 Work-Related Hearing Loss
 Asbestos-Related Illness
 Work-Related Coronary/Vascular Condition
 Work-Related Skin Disease
 Work-Related Pulmonary Illness (not asbestosis)
 Work-Related Psychiatric Illness
 Work-Related Carpal Tunnel Syndrome
CA-2a, Notice of Recurrence
 Recurrence of Medical Condition
 Documented need for additional medical treatment
after release from treatment for the work-related injury.
 Recurrence of Disability
 Spontaneous return of the symptoms of a previous
injury or occupational disease without an intervening
cause.
CA-2a (cont)
 Employee completes and signs page one of the form
 Supervisor will review employee’s portion of the form
and complete page two
 Treated the same as a CA2 in that it is not considered
work-related unless DOL accepts the recurrence.
CA-6, Official Superior’s Report
of
Employee’s Death
CA-5 and CA-5b, Claim for
Compensation by Widow,
Widower, and/or Children,
Parents,
Brothers, Sisters, Grandparents,
or
Grandchildren
CA-5 and CA-5b (cont)
 Benefits may be paid to eligible dependents of an
employee whose death results from an injury sustained
in the performance of duty.
CA-7 Claim For Compensation
CA-16, Authorization for
Examination and/or Treatment
 Complete the form with 4 hours of request
 May refuse to issue if more than a week has passed
since the injury
CA-17, Duty Status Report
 To obtain interim medical reports
 Issued with the CA-16
 Supervisor completes the agency portion of the form
 May send to the physician at reasonable intervals
 Monitor employee’s medical status and ability to
return to limited or full duty
Work Statements and Limited
Duty Job Assignments
Memorandum
Date:
From:
Workers’ Compensation Program Office or Supervisor (Name/Title)
Subj:
Transitional Duty Assignment
To:
Thru:
Employee (Name/Title)
1. The purpose of this memorandum is to inform you that the following transitional duty
assignment is offered to you as a result of your work-related injury of (Date of Injury). Your
physician has indicated that you may return to work on (Date), with the following medical
restrictions:



List Restrictions.
List Restrictions.
List Restrictions.
(Reference medical note/Form CA-17, etc., dated XX-XX-XX.)
2. A transitional duty assignment that meets your physical restrictions has been identified and is
available. Effective (Date), you will be given a transitional duty assignment on your unit. Your
tour of duty will be (List days of week and tour of duty hours). You will retain your current salary
of (insert grade/step and salary) during this assignment. This transitional duty assignment will
continue until your physician provides medical evidence to support a change in your restrictions
or the service no longer has transitional work available, at which time a new transition duty
assignment will be issued.
3. Your transitional duty assignments will consist of the following:


List duty assignments.
List duty assignments.
Physical requirements: (List requirements) (Example: You will be required to sit for 4 hours
intermittently and/or walk 4 hours intermittently. No lifting over 5 pounds. No pushing or pulling
or bending. You may sit or stand within the immediate work area.
4. At no time are you to engage in any activity that could harm or aggravate your condition. It
will be your responsibility to communicate your restrictions to anyone who may inadvertently
make an assignment that exceeds these restrictions. You are to promptly provide your
supervisor any and all physician statements and/or changes in restrictions that may impact your
ability to perform your transitional duty assignment.
5. Please be advised that you are obligated under federal regulations to work in an available
transitional duty assignment that meets your medical restrictions. If you refuse to accept the
employment offer or to perform the transitional duty assignment, it may result in termination of
your workers’ compensation benefits. In addition, any resulting absence may be charged as
Absent Without Leave (AWOL), and an administrative action may be initated. Please indicate
your acceptance or declination of this transitional duty assignment as indicated below.
6. We hope that this assignment will provide you with sufficient time to recover from your work
injury while also making available gainful employment and continued income. If you have any
questions concerning this matter you may contact me at (phone number).
(Workers’ Compensation or Supervisor Name/Signature)
cc: Workers’ Compensation Program Manager
U.S. Department of Labor (DOL)/Office of Workers’ Compensation Programs (OWCP)
____________________________________________________________________________
__________ I accept the transitional duty assignment described above.
__________ I decline the transitional duty assignment as described above for the following
reason(s):
____________________________________________________________________________
____________________________________________________________________________
I understand that acceptance or refusal of this transitional duty assignment must be provided to
the DOL OWCP. In accordance with Title 5, USC 8106(c), a partially disabled employee who
(2) “refuses or neglects to work after suitable work is offered to, procured by, or secured for him;
is not entitled to compensation.”
____________________________________________________
Employee Signature and Date
Continuation of Pay
Memorandum
Yvette Talley______________________________________________________________
To:
1st Level Supervisor; 2nd Level Supervisor
CC:
My Supervisor; Payroll Supervisor; Safety Manager;
Service Timekeeper
Subject:
COP-(Initials) 2012-00001
As a result of claim of traumatic injury on Month, Day, Year the following
absences are authorized for charge to COP (unless otherwise indicated) as
elected on CA-1 by First MI Last.
3/1/11, Date of Injury, Authorized Absence (2:30 pm - 4:30 pm/2 hrs)
3/7/11 (8:00 am-12:00 noon/4 hours/appt)
3/18/11 thru 3/21/11
Total Cumulative COP= 5 calendar days
Note: Additional absences possible. COP entitlement period expected to end on
4/16/11. Related absences AFTER 4/16/11 should be charged to appropriate leave
and/or leave without pay (LWOP)
Yvette Talley
FWCP Specialist, VISN 9
Robley Rex VA Medical Center
Louisville, KY
502-287-6175
Fax 502-287-6978
Confidentiality Note: This e-mail is intended only for the person or entity to which
it is addressed and may contain information that is privileged, confidential or
otherwise protected from disclosure. Dissemination, distribution or copying of
this e-mail or the information herein by anyone other than the intended recipient is
prohibited. If you have received this e-mail in error, please notify the sender by
reply e-mail and destroy the original message and all copies
OWCP Decision on Denied
Claim-Agency Email
Notification
Yvette Talley______________________________________________________________
To:
Supervisor; Service Chief
CC:
My Supervisor; HR POC; Safety Manager; Occupational Health
Subject:
OWCP Decision- (Initials)
By copy of letter dated Month, Day, Year to FIRST MI LAST, and received by FWCP
Office on Month, Day, Year, the U.S. Department of Labor, OWCP, has advised this
office the claim for traumatic injury on Month, Day, Year has been denied due to
insufficient evidence. Medical treatment at OWCP expense is not authorized and
prior authorization, if any, is hereby terminated. Employee was furnished appeal
rights with this notice, but to date has not exercised any appeal through this
office.
Employee has returned to full duty relative to the claimed injury/condition.
If you have any questions or concerns regarding this message, please do not
hesitate to contact this office at ext. xxxx.
Yvette Talley
FWCP Specialist, VISN 9
Robley Rex VA Medical Center
Louisville, KY
502-287-6175
Fax 502-287-6978
Confidentiality Note: This e-mail is intended only for the person or entity to which
it is addressed and may contain information that is privileged, confidential or
otherwise protected from disclosure. Dissemination, distribution or copying of
this e-mail or the information herein by anyone other than the intended recipient is
prohibited. If you have received this e-mail in error, please notify the sender by
reply e-mail and destroy the original message and all copies.
Yvette Talley______________________________________________________________
To:
Supervisor; Service Chief
CC:
My Supervisor; HR POC; Safety Manager; Occupational Health
Subject:
OWCP Decision- (Initials)
By copy of letter dated Month, Day, Year to FIRST MI LAST, and received by FWCP
Office on Month, Day, Year, the U.S. Department of Labor, OWCP, has advised this
office the claim for traumatic injury on Month, Day, Year has been denied due to
insufficient evidence. Medical treatment at OWCP expense is not authorized and
prior authorization, if any, is hereby terminated. Employee was furnished appeal
rights with this notice, but to date has not exercised any appeal through this
office.
Employee is on limited duty relative to the claimed injury/condition, however, any
coordination involving work capacity of this employee should be addressed with
Human Resources Management Service as s/he is not covered by OWCP and is
not entitled to benefits under the Federal Employees’ Compensation Act (FECA).
If you have any questions or concerns regarding this message, please do not
hesitate to contact this office at ext. xxxx.
Yvette Talley
FWCP Specialist, VISN 9
Robley Rex VA Medical Center
Louisville, KY
502-287-6175
Fax 502-287-6978
Confidentiality Note: This e-mail is intended only for the person or entity to which
it is addressed and may contain information that is privileged, confidential or
otherwise protected from disclosure. Dissemination, distribution or copying of
this e-mail or the information herein by anyone other than the intended recipient is
prohibited. If you have received this e-mail in error, please notify the sender by
reply e-mail and destroy the original message and all copies.
QUESTIONS?
Yvette Talley
Robley Rex VAMC
Louisville, KY
[email protected]
1-502-287-6175
Mark Baumann
James H. Quillen VAMC
Mountain Home. TN
[email protected]
1-423-926-1171, ext 7168