Division of Federal Employees' Compensation (DFEC)
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1. Background. The Office of Workers' Compensation Programs (OWCP), Division of Federal Employees' Compensation (DFEC), administers a Nurse Intervention Program to utilize nurse case managers to assist with the medical recovery and return to work (RTW) efforts of the Injured Worker (IW). This effort involves a collaborative process between the IW, Claims Examiner (CE), Continuation of Pay (COP) Nurse, treating physician/medical provider(s) and the employing agency (EA). Assignment of a COP Nurse (CN) occurs during the early phase of a traumatic work injury, prior to initial case adjudication.
This handbook is intended to be used by all OWCP/DFEC contracted CNs certified with the Nurse Intervention Program handling cases in connection with the Federal Employees' Compensation Act (FECA), 5 U.S.C. 8101 et seq.; 20 CFR Part 10, Subpart C. Its purpose is to provide CNs with information necessary to understand and adhere to performance expectations in assigned cases.
Effective September 7, 1974, the FECA was amended at 5 U.S.C. 8118 to authorize the EA to continue an IW's pay for a period not to exceed 45 days, pending the OWCP's adjudication of the IW's claim for compensation. Continuation of Pay (COP), as defined in 20 C.F.R §10.200, applies only to traumatic injuries occurring on or after November 6, 1974 and reported on an OWCP claim form within 30 days. The intent of the COP provision is to eliminate interruption in the IW's income for the period immediately following a job-related traumatic injury.
a. A traumatic injury is defined as a condition of the body caused by a specific event or incident, or series of events or incidents, within a single workday or shift. Such condition must be caused by external force, including stress or strain, which is identifiable as to time and place of occurrence and member or function of the body affected. Traumatic injury claims are filed on a Form CA-1 (Notice of Traumatic Injury).
The COP Nurse (CN) Intervention Program was developed and implemented in September, 2000 as part of the President's Federal Worker 2000 initiative. This initiative, implemented at the direction of the Secretary of Labor, set specific goals for reducing overall occurrence of work place injuries, improving the timeliness of reporting of injuries and illnesses to the Department of Labor (DOL), and reducing the rate of lost production days (LPD) per fiscal year. The emphasis for the program was prompt adjudication and payment of benefits, early intervention in certain traumatic injuries, active management of these cases, as well as prompt/appropriate RTW efforts. OWCP determined that a pre-adjudicatory nurse intervention program geared toward early identification and triaging of these cases would assist in achieving the goals of the President's initiative.
In 2010, the DFEC implemented a more comprehensive and expedited process for management of certain traumatic injury cases. Included in this new process was the ability of the CN to view certain applications within OWCP's electronic case management system in order to obtain information for CN case assignments directly from the OWCP case file. In addition, the CN process was enhanced to incorporate the completion and submission of the CN report and associated documents, including billing invoices, via the CN's web-based "home page." As noted in more detail in Paragraph 7 below, the CN is strictly a triage nurse and all work is performed telephonically.
Subsequently, these technological advances have allowed the CN to focus intervention efforts on the medical management aspect of the claim. Streamlining the process has provided the CN with the time and tools necessary to address and assess key factors of the assigned claim and efficiently communicate case findings to the District Office. Such efforts have assisted the CE in expediting the decision making process related to the initial adjudication and case management of the claim.
Additional information related to the COP Nurse Intervention Program may be found in the FECA Procedure Manual Chapter 2-811, Nurse Case Management, and the FECA Procedure Manual Chapter 7-0300, Continuation of Pay (COP) Nurses.
"The Integrated Federal Employees' Compensation System COP RTW User Manual – revision 2.2, January 13, 2011" contains the technical components of the CN process. This manual provides the information necessary for the CN to use in the Integrated Federal Employees' Compensation System (iFECS) application to perform CN-related tasks.
2. Purpose and Scope.
a. This handbook focuses on the following topics:
(1) Objectives of the CN Intervention Program;
(2) Roles and responsibilities of key participants in the CN Intervention Program;
(3) CN assignments, activities, and time frames;
(4) CN reporting/billing requirements and procedures; and
(5) Relevant information regarding the security and use of case file information consistent with the Privacy Act and OWCP/DFEC's routine uses.
b. Structure. This handbook begins with a brief overview of the DFEC program and structure. The remainder of the handbook is devoted to the CN Intervention Program's structure, policies, and guidelines.
3. DFEC Overview. The FECA provides workers' compensation coverage to three million Federal and postal workers around the world for employment-related injuries and occupational diseases. It covers all civilian Federal employees except non-appropriated fund employees. In addition, special legislation provides coverage to Peace Corps and VISTA volunteers; Federal petit or grand jurors; volunteer members of the Civil Air Patrol; Reserve Officers' Training Corps Cadets; Job Corps and Youth Conservation Corps enrollees; and non-Federal law enforcement officers under certain circumstances involving crimes against the United States. Temporary employees are covered on the same basis as permanent employees. See 5 U.S.C. 8101 et seq.; 20 C.F.R. Part 10.
Benefits include wage replacement, payment for medical care, and where necessary, medical and vocational rehabilitation assistance in returning to work. With the exception of COP, FECA benefits are paid from the Employees' Compensation Fund, and then charged back to the Federal employing agencies through the budget process in a subsequent year. Note: Postal Services employees are not entitled to receive COP for the first three days of temporary disability unless the disability exceeds 14 days. See 20 C.F.R. 10.200 (c).
Additionally, not all individuals covered by FECA are entitled to COP. For example, Job Corps students and Peace Corps volunteers may not receive COP. See 20 C.F.R. 10.200 (4).
a. Jurisdiction and Office Structure. There are 12 District Offices, each headed by a District Director, who is responsible for overseeing claims administration. Each District Office has designated areas of responsibility and jurisdiction, which are provided at: http://www.dol.gov/owcp/contacts/fecacont.htm
b. District Office Staff. Supervisory Claims Examiners are responsible for the operation of individual claims units. Senior Claims Examiners and Claims Examiners (CE) are responsible for the adjudication, payment, and management of claims. Staff Nurses (SN) oversee the Nurse Intervention Program in the district, and Rehabilitation Specialists (RS) oversee the Vocational Rehabilitation Program in the district.
Additional information about the DFEC can be found on the following website: http://www.dol.gov/owcp/dfec/index.htm
4. Objectives of the CN Intervention Program. The OWCP is committed to seeing that benefits for compensation and medical services are appropriately and timely provided. The OWCP is also committed to assisting injured workers (IW) in obtaining a successful medical recovery and minimizing the period of disability from work.
To further these goals, OWCP created the CN Intervention Program. Involving nurses in the early stages of certain disabling traumatic injury cases (even prior to case adjudication) facilitates expedited case adjudication, prompt medical care and recovery, and can result in shortening the length of disability from work. The objectives of the CN Intervention Program include, but are not limited to:
a. Facilitating communications between the IW, employing agency (EA), medical provider(s), and the CE by providing information related to the status of the claim and the recommended actions necessary to assist the IW in obtaining medical care and recovery related to the reported work injury;
b. Expediting the submission of medical documentation to the CE to facilitate prompt adjudicatory decisions, thereby expediting medical care and reducing the length of the disability associated with traumatic work injuries;
c. Assisting the IW, EA, and medical provider(s) in the OWCP process; and
d. Identifying cases that may benefit from an assignment of an OWCP/DFEC contracted Field Nurse.
5. Participants in the CN Intervention Program.
a. The District Office Staff Nurse (SN). Each District Office retains the services of a SN to administer the policies and procedures of the OWCP Nurse Intervention Program (NIP), which includes contracted CNs and contracted Field Nurses. The SN directs contract nurse services in accordance with OWCP/DFEC policies and procedures related to the NIP to ensure quality, effective, and timely services. The SN facilitates the interactions and communications between the NIP participants, and also identifies medical issues or obstacles that need prompt attention. The duties of the SN include, but are not limited to:
(1) Managing assignments of contracted nurses to OWCP cases;
(2) Monitoring contract nurses' performance in correlation to both the contract specifications and the quality of services provided, and intervening promptly to address work product issues when deficiencies occur;
(3) Consulting with the CE and CN/Field Nurse regarding treatment plans and medical services so that established case management goals are being accomplished;
(4) Reviewing, evaluating, and processing nurse reports to ensure completeness and timeliness prior to authorizing payment of bills;
(5) Developing working relationships with, and serving as a liaison and resource for, EAs and their representatives in order to establish positive and productive communications; and
(6) Serving as the District Office subject matter expert regarding nurse intervention policy and services.
b. The District Office Claims Examiner (CE). The CE maintains authority over all case management actions. The CE is responsible for the following types of actions/decisions:
(1) Determining benefit eligibility, developing, approving and/or denying compensation payments and benefit rate adjustments;
(2) Developing, authorizing, and/or denying medical services, treatment plans, hospitalizations, etc.;
(3) Identifying cases in need of Field Nurse services and completing the referrals to the SN as quickly as possible;
(4) Consulting and communicating with assigned contract nurses concerning case management activities and progress;
(5) Reviewing nurse reports and medical treatment plans to ensure that they are in keeping with the established goals and objectives so that the case management activities proceed according to the FECA guidelines;
(6) Evaluating and determining suitability of job offers; and
(7) Identifying cases in need of referrals to OWCP's Vocational Rehabilitation Program.
c. The OWCP/DFEC Certified COP Nurse (CN). CNs are contracted nurses assigned to traumatic injury cases where the IW has immediate time loss and has not returned to work within seven (7) days following the date of work stoppage. The CN enables the District Offices to identify cases in need of prompt adjudication and assists the CEs in prioritizing their adjudication efforts.
6. Identification of Cases for CN Assignment.
a. Based on the data entered when a traumatic injury case is created from Form CA-1 (specifically, the date the IW stopped working), a case becomes automatically eligible for CN assignment if all of the following conditions are met:
(1) It is a traumatic injury case;
(2) The IW stopped work at least 7 days ago;
(3) The IW stopped work less than 31 days ago;
(4) The IW has not returned to work;
(5) The IW is in a COP status (based on the checkbox on the Form CA-1); and
(6) The case is an administratively closed case or its current status is either Unreviewed (UN) or Under Development (UD).
b. Traumatic injury cases meeting the criteria above are automatically referred to the SN for assignment to a CN and the assignments are made through the DFEC integrated computer system. When the SN makes the assignment, it is recorded and tracked. The CN is usually assigned on a rotational basis if there is more than one CN per state/territory. The CN assignment is generally initiated on day 8 after the reported injury. These assignments occur even though the case has not yet been formally accepted.
c. The CN accesses his/her case assignments electronically via remote access to the DFEC integrated computer system and the COP Case Processing application. The CN can view only his/her open cases, cases requiring action, and new assignments. The CN is also provided read-only access to other applications that may provide additional case file information necessary to complete the assignment.
7. CN Timeframes, Interventions, and Documentation. A CN is assigned to provide limited medical intervention during the early stages of a work stoppage due to certain reported traumatic work injuries. Although CN intervention is not extensive during the COP period (the assignment period being limited to 7 days-with the specific exception noted in Paragraph 8a), the medical knowledge and experience of a CN assists with the identification and triaging of cases that require more extensive intervention due to the severity of the injuries, contemplated surgical intervention(s), or lost time from work. The CN is strictly a triage nurse and all work is performed telephonically.
a. In order to effectively triage the case, within 7 days of case assignment the CN should:
(1) Contact the IW to obtain a history of injury, history of treatment, and current work status, as well as physician contact information.
(2) Contact the EA to confirm the IW's current work status and ascertain whether light duty work accommodations are available, if needed.
(3) Contact the treating physician's office to obtain a history of treatment, the expected treatment plan and, if available, the date of the IW's next appointment. At that time, the CN can also provide general information regarding communication with the OWCP (such as the address for submission of treatment notes/reports), how to submit medical authorization requests, and how to submit bills should the case subsequently be approved. The CN should also advise the physician's office whether light duty work accommodations can be provided based on the prior contact with the EA and, if appropriate, provide a Form CA-20, Attending Physician's Report, requesting that it be completed and submitted to OWCP.
b. As the CN gathers the information, s/he should open the COP Case Processing application to enter the activity and related information as it is obtained. The data is populated into the automated COP Activity Log and COP Worksheet (also referred to as the COP Nurse Report), which all become part of the OWCP electronic case file upon closure (and approval by the SN). The reportable activities may include the CN providing comments and/or recommendations resulting from the nurse triage activities noted above, registering telephone contacts, recording requests for medical records from the IW's provider(s), advising of case assignment closure, and documenting the dispensation of case file materials.
8. CN Case Assignment Closure and Bill Payment. Closure of a CN case assignment occurs when the CN has taken the necessary actions for the case and has entered a reason for closure via a drop-down menu located on the automated COP Worksheet. The CN should note in the designated areas any updates or other pertinent information that may assist the CE in making purposeful decisions related to further case management actions, as warranted.
a. The CN should obtain the necessary information, as outlined above, and close the case assignment within 7 days of the assignment date. However, if the CN determines that the IW will be returning to work within the following week, and the specific contact information supporting a definitive RTW date has been entered into the COP Case Processing application, the CN assignment can remain open beyond the 7-day time limit in order to verify and report the RTW date and status. However, in these specific situations, the CN case assignment closure should still occur no later than 14 days after the initial assignment.
b. When the CN closes the case assignment, he/she is required to confirm appropriate handling/destruction of case file records. This is accomplished via an automated process in the COP Case Processing application: Certification of PII (Personally Identifiable Information). This must be selected at the time of CN case assignment closure in order for the SN to approve the COP Worksheet (COP Nurse Report) and process the billing for the CN services provided.
c. Upon CN case assignment closure, the COP Worksheet (COP Nurse Report) should also document: the RTW status, any relevant information pertaining to possible issues or concerns regarding the recovery process or potential barriers to the RTW effort, and provide a recommendation regarding early intervention and assignment to a Field Nurse.
d. The SN then reviews the CN documents for appropriateness and accuracy. Once the SN has approved the CN case assignment closure, the COP Worksheet (COP Nurse Report) and Activity Log are automatically generated for submission into the OWCP electronic case file.
e. Upon the SN's approval of the CN case assignment closure, a bill for CN services is automatically generated to the designated central bill payment processing facility. Payment is issued to the CN upon the successful processing of this bill.
9. Security of Case Information and the Privacy Act. As custodians of FECA beneficiaries' personal information, the Government and its contract CNs have a responsibility to protect this information. As every case file contains sensitive personal and medical information, release of those documents to unauthorized parties is inherently inappropriate, and may constitute a violation of law.
a. Privacy Act. The Privacy Act (PA) mandates that personal information about individuals collected by Federal agencies must be limited to that which is legally authorized and necessary, and must be maintained in a manner which precludes unwarranted intrusions upon individual privacy. See 5 U.S.C. 552a and 29 C.F.R. Part 71.
The PA imposes on government employees and contractors certain obligations and responsibilities concerning the maintenance, care, and use of records. The PA, which assures private citizens the right to confidentiality of certain personal records/information, sets forth the government's responsibility to properly maintain and restrict access to these records.
Since the FECA workers' compensation case files constitute a PA system of records (i.e. the record is maintained under, and retrieved by, the individual's own name), the DFEC follows the provisions and principles of the PA. The system of records in which FECA claims are maintained is DOL/GOVT-1, viewable at http://www.dol.gov/sol/privacy/dol-govt-1.htm.
b. Release of Information. If there is any doubt regarding whether a record may be disclosed, the CN should contact the SN for guidance.
(1) Disclosure. The IW has the right to a copy of his/her case file at any time, unless the file contains medical information which could be harmful if released. Disclosure of the case file to anyone else is generally prohibited without the express written consent of the IW.
"No agency shall disclose any record which is contained in a system of records by any means of communication to any person, or to another agency, except pursuant to a written request by, or with the prior written consent of, the individual to whom the record pertains, unless disclosure of the record would be...for a routine use as defined in subsection (a)(7)" {5 U.S.C. § 552a(b)(3)}.
(2) Routine Use. There are a number of exceptions to this rule, however, called routine uses, which permit case file information to be used when necessary to carry out program responsibilities.
"The term "routine use" means, with respect to the disclosure of a record, the use of such record for a purpose which is compatible with the purpose for which it was collected." {5 U.S.C. § 552a(7)}
This means that the OWCP can properly use information from the case file without first obtaining the IW's permission. There are 12 universal routine uses, which can be accessed at http://www.dol.gov/sol/privacy/intro.htm
c. Disclosure to CNs. OWCP's authority to disclose certain relevant records to contract CNs without written consent is addressed under universal routine use #6:
"6. To disclose to contractors, employees of contractors, consultants, grantees, and volunteers who have been engaged to assist the agency in the performance of or working on a contract, service, grant, cooperative agreement or other activity or service for the Federal Government."
Disclosure to CNs is also authorized by routine use k of DOL/GOVT-1.
d. Contractor Non-Disclosure Agreement. Each CN is tasked with adhering to the PA and protecting Personally Identifiable Information (PII). In order to ensure understanding and cooperation in this matter, the OWCP uses a Non-Disclosure Agreement that is to be signed by each CN. This document is a detailed description of what is expected from a CN in regards to fulfilling the terms of the PA legislation and protecting PII. It is his/her binding agreement to abide by the standards set forth by the Department of Labor. When in doubt, a CN should seek clarification from OWCP (via the SN) before responding to, or taking action on, any issue involving the PA or PII.
e. Criminal Penalties. Failure to comply with any security requirements could subject a CN to criminal penalties, including a fine of up to $5,000. See 5 U.S.C. § 552a(i)(1)-(3).