A GUIDE TO INJURY COMPENSATION FEDERAL EMPLOYEES AND SUPERVISORS

A GUIDE TO INJURY COMPENSATION FOR FEDERAL EMPLOYEES AND SUPERVISORS 1 COMPILED BY THE HUMAN RESOURCES AND ORGANIZATIONAL MANAGEMENT BRANCH ADMINISTRATION AND RESOURCE MANAGEMENT DIVISION PROGRAMS AND RESOURCES DEPARTMENT HEADQUARTERS, U.S. MARINE CORPS 2 TABLE OF CONTENTS CHAPTER 1: INTRODUCTION ......................................................................................................................... 4 CHAPTER 2: OVERVIEW OF THE FECA PROGRAM ................................................................................. 5 What is the Federal Employees Compensation Act (FECA)? Who Administers the FECA? Who May I Contact at My Activity if I Have Questions? What Forms are Required if I Need to File a FECA Claim? CHAPTER 3: WHAT FECA COVERS ............................................................................................................... 6 Traumatic Injury Occupational Disease or Illness Recurrence CHAPTER 4: FECA BENEFITS ......................................................................................................................... 7 Continuation of Pay Wage Loss Payment for Medical Expenses Travel Reimbursement Vocational Rehabilitation Scheduled Awards Death Benefits CHAPTER 5: TRAUMATIC INJURIES ............................................................................................................ 9 Notification of Traumatic Injury Authorization for Medical Treatment Medical Documentation Election of Continuation of Pay (COP) or Leave How COP is Counted Controverting and Terminating COP Wage Loss Forms Needed for a Traumatic Injury Claim CHAPTER 6: OCCUPATIONAL ILLNESS AND DISEASE ........................................................................... 13 Notification Requirement Additional Documentation Required Exclusions Claiming Wage Loss Compensation Forms Needed for Occupational Disease Claims CHAPTER 7: RECURRENCE .......................................................................................................................... 15 Types of Recurrences Notification Requirement Forms Needed for Claims of Recurrence CHAPTER 8: LEAVE BUY BACK ...................................................................................................................... 17 Forms Needed for Leave Buy Back CHAPTER 9: EMPLOYEE RIGHTS AND RESPONSIBILITIES ................................................................ 19 CHAPTER 10: SUPERVISOR’S RIGHTS AND RESPONSIBILITIES ......................................................... 20 CHAPTER 11: REIMBURSEMENT FOR OUT OF POCKET MEDICAL AND TRAVEL EXPENSES ............................................................................................................... 21 Medical Expenses Travel Expenses CHAPTER 12: MISCELLANEOUS PROVISIONS .......................................................................................... 22 Timekeeping Bill Payment and Medical Authorizations Electronic Data Interchange CHAPTER 13: FREQUENTLY ASKED QUESTIONS ..................................................................................... 23 CHAPTER 14: SOME HELPFUL RESOURCES .............................................................................................. 28 3 CHAPTER 1: INTRODUCTION This guide is intended to provide employees with basic information about the Federal Employees Compensation Act (FECA). The FECA provides certain benefits and entitlements to employees who suffer an injury or become ill as a result of their employment. The FECA program can be complicated, involving a variety of forms, deadlines, and processes. Your Human Resources Office stands ready to assist you with the forms and processes established to report workplace injuries and illness and to obtain the benefits to which you are entitled. While we hope that you never have a reason to use this guide, we trust that the information provided will assist you through the process should you ever have a need for it. 4 CHAPTER 2: OVERVIEW OF THE FECA PROGRAM WHAT IS THE FEDERAL EMPLOYEES COMPENSATION ACT (FECA)? The FECA provides compensation benefits to federal employees who are disabled due to injury or illness sustained while in the performance of duty. The FECA also provides for payment of benefits to dependents if a work related injury or illness causes the employees death. Benefits under FECA constitute the sole remedy available to Federal employees against the U.S. government for work-related injury, illness or death. A Federal employee or surviving dependent is not entitled to sue the United States or recover damages for such injury, illness or death under any other law. WHO ADMINISTERS THE FECA? The Department of Labor (DOL), Office of Worker’s Compensation Programs (OWCP), is responsible for reviewing claims filed by federal employees. All entitlement decisions are made by DOL. WHO MAY I CONTACT AT MY ACTIVITY IF I HAVE QUESTIONS ABOUT THE FECA OR WANT TO FILE A CLAIM? The point of contact for employees at the activity level is the Injury Compensation Program Administrator (ICPA). The ICPA is usually located within the Human Resources office and is responsible for management of the local FECA program. The ICPA will assist employees and supervisors with most aspects of the claims process including the completion and filing of claims with OWCP. The ICPA will ensure that the documents submitted are correct and accurate prior to being submitted to OWCP and that all follow up documentation is forwarded in a timely manner. WHAT FORMS ARE REQUIRED IF I NEED TO FILE A FECA CLAIM? The DOL has established many forms that are used in connection with the FECA program. The injured employee will complete some forms while the employee’s supervisor and physician will complete others. The various forms used are discussed in this guide, and a summary is provided, with links to forms, as they relate to each of the type of injuries and illnesses covered in the guide. The ICPA at the Human Resources Office is your main point of contact for determining which forms are required, where to get them, and how to file them. 5 CHAPTER 3: FECA COVERAGE Three types of conditions are covered by the FECA: TRAUMATIC INJURY A traumatic injury is a wound or condition of the body that is caused by an event or series of events within a single shift. The injury must be such that it can be identified as a condition, which happened at an identifiable time and place. The employee must also be able to show that a causal relationship exist between the injury and the part of the body effected. Examples of traumatic injuries include breaking a leg or cutting a finger while in the performance of duties. A traumatic injury can include stress or strain to portions of the body as well as damage or destruction of prosthetics. For instance, eyeglasses will be covered provided they were damaged due to a work related injury requiring medical care. OCCUPATIONAL DISEASE OR ILLNESS An occupational disease or illness is a condition produced in the work environment over a period longer than one workday or shift. It may result from systemic infection, repeated stress or strain, exposure to toxins, poisons, fumes, or other continuing conditions of the work environment. RECURRENCE A recurrence of disability is a spontaneous return or increase of disability without intervening cause or return or increase of disability due to a consequential injury. A recurrence of disability differs from a new injury in that with a recurrence, no event other than the previous injury accounts for the disability. A recurrence of a medical condition is defined as a documented need for further medical treatment after initial release from treatment but with no accompanying work stoppage. WHY DO I NEED TO UNDERSTAND WHETHER I HAVE A TRAUMATIC INJURY, AN OCCUPATIONAL ILLNESS OR DISEASE, OR A RECURRENCE? The forms that are completed for filing claims for traumatic injury, occupational illness or disease, and recurrences are different. Additionally, some of the FECA benefits are different. While most times it will be clear as to what type of claim should be filed, when there is a question, the ICPA will assist you in determining whether your condition is most likely to be a traumatic injury, occupational illness or disease, or recurrence. 6 CHAPTER 4: THE BENEFITS UNDER THE FECA PROGRAM CONTINUATION OF PAY (COP) The FECA provides that an employee’s regular pay may continue for up to 45 calendar days of disability following a traumatic injury. Use of COP must be supported by medical evidence. COP does not apply in occupational illness and disease cases. COP is discussed in more detail in Chapter 5 of this guide. WAGE LOSS When an employee is disabled for work as a result of traumatic injury, beyond the 45 days authorized for COP, the employee may claim compensation for wage loss. There is a 3-day waiting period that employees will not be paid for unless their disability extends 14 days beyond COP. The normal rate of compensation is 75% for those with dependants and 66 2/3% for those without. Compensation is tax free and, if the period of disability extends beyond 28 days, includes deductions for health insurance, life insurance and retirement benefits though thrift savings plan (TSP) contributions are not included nor will TSP loan payments be deducted. To file for wage loss, employees must submit a CA-7 (Claim for Compensation), a CA-20 (Attending Physician Report) or another form of medical documentation such as comprehensive medical notes. In cases where absence from work is intermittent, a CA-7a (Time Analysis Sheet) must also be provided. PAYMENT FOR MEDICAL EXPENSES Under the FECA, an injured employee is entitled to the payment of medical bills incurred for the treatment of any accepted work-related condition. This includes all treatment, appliances, and supplies prescribed or recommended by a qualified physician that, in the opinion of the DOL, are likely to cure, give relief, reduce the degree of period of disability, or aid in lessening the amount of wage loss compensation. Chiropractic treatment is covered under the FECA only when it involves the manual manipulation of the spine to correct a spinal subluxation, which has been demonstrated by x-ray to be present, or if a medical doctor has prescribed physical therapy by a chiropractor. Chiropractic treatment must be pre-approved by DOL. TRAVEL REIMBURSEMENT Unless transportation is provided by the government, an employee may be reimbursed for travel expenses to obtain medical care. An employee who uses his/her own automobile will be reimbursed at the standard mileage rate for government travel. Wages and travel expenses of an attendant to accompany the employee may be approved if travel cannot be accomplished otherwise. Authorization for this expense should be obtained in advance from the DOL whenever possible. 7 VOCATIONAL REHABILITATION The FECA provides for vocational rehabilitation services to assist disabled employees in returning to gainful employment consistent with their physical, emotional and educational abilities. An employee with an extended disability may be considered for rehabilitation services if requested by the attending physician, the employee, or agency personnel. Additionally, the OWCP will routinely consider a case for rehabilitative services if the agency cannot find a position suitable for reemployment. SCHEDULED AWARDS Compensation is paid for specified periods of time for the permanent loss, or loss of use, of certain members and functions of the body. Partial loss or loss of use of these members and functions is compensated on a prorated basis. The DOL has developed a compensation table for scheduled awards. For example, in the current table maintained by DOL, an employee would be entitled to a scheduled award amounting to 312 weeks of pay for loss of an arm in the performance of duty. DEATH BENEFITS The survivors of Federal employee whose death is work-related are entitled to benefits in the form of compensation payments, funeral expenses, and transportation expenses for the remains, if necessary. 8 CHAPTER 5: TRAUMATIC INJURIES NOTIFICATION OF TRAUMATIC INJURY When a traumatic injury occurs, employees are responsible for notifying the supervisor as soon as possible. Depending on the severity of injury, the employee can be sent to the dispensary for medical care or emergency medical services should be contacted. If the employee so chooses, he may go to his personal medical provider rather than the agency physician. If a personal physician is elected, a CA-16, (Authorization for Medical Treatment) shall be issued provided the restrictions discussed in the below section “Authorization for Medical Treatment” are followed. Written notification of an injury must be provided on a CA-1, (Notice of Traumatic Injury and Claim for Compensation), as soon as feasibly possible. If the injured worker is incapacitated, the CA-1 may be completed and submitted by a representative such as a family member, co-worker, union official or the supervisor. CA-1 forms must contain the original signature of the person giving notice. Once completed and received by the ICPA, the CA-1 must be submitted to the Office of Worker’s Compensation Programs (OWCP) within 10 working days of receipt. When feasible, employees will complete the Employee Data portion of the CA-1 and supervisors will complete the Supervisors Report and Receipt of Notice of Injury portions. Two copies of the completed CA-1 will then be made, one copy will be maintained by the supervisor, one copy will be given to the employee and the original will be forwarded to the ICPA. AUTHORIZATION FOR MEDICAL TREATMENT A CA-16 authorizes immediate medical attention for employees when a traumatic injury occurs and guarantees payment associated with the work related injury. CA-16 forms should be issued within 4 hours of the injury when possible. The reverse side must be completed by the treating physician, which must be submitted as the initial medical report. A copy of the report will be forwarded to both OWCP and to the Agency. The CA-16 also serves as a notice to the physician if it is believed that the injury did not occur as a result of a condition of employment. If the initial treating physician refers the injured worker for testing or to a specialist, the original CA-16 will be valid for treatment as a result of the referral for up to 60 days from the date of issue. A CA-16 cannot be issued by the agency if a week or more has passed since the date of injury, nor can it be issued in cases of occupational illness without the consent of OWCP. MEDICAL DOCUMENTATION Supporting medical documentation must be submitted, through the ICPA to OWCP, within 10 working days of the submission of the CA-1. Failure to provide medical evidence within the specified timeframe is grounds for termination of COP. Initial medical documentation can be provided on a CA-16, a CA-20 (Physicians Report) or through comprehensive medical notes. A CA-20 presents a series of questions for the attending physician to answer regarding the employee’s medical condition. It provides supporting medical documentation for the injured worker’s claim and should be filled out upon completion of medical examination or treatment. A CA-17 (Duty Status Report) provides information to the agency and OWCP regarding the employee’s physical capability for returning to work. The left side of the CA-17 will be filled out by the supervisor indicating the physical demands of the injured worker’s regular position. The form should be given to the employee to be filled out by the physician at reasonable intervals, normally every two weeks. 9 ELECTION OF CONTINUATION OF PAY (COP) OR LEAVE When the CA-1 form is completed, the injured worker will have to make an election as to whether to elect continuation of pay (COP) or annual/sick leave should you need to be absent due to disability or medical treatment. However and very importantly, employees are responsible for submitting a completed CA-1 within 30 days from the date of injury in order to be eligible for COP. Additionally, employees are responsible for submitting supporting medical documentation within 10 working days. Failure to provide medical evidence within the specified time frame is grounds for termination of COP. If COP is elected, regular pay, including night and shift differentials, will be continued for up to 45 calendar days, provided the employee is disabled from the injury and provides medical documentation to support the period of disability. If the claim is later denied by the DOL, any COP used will be charged to sick or annual leave or will be deemed to be an overpayment. If leave is elected to cover absences due to a traumatic injury, each day of leave will be counted against the 45 days of entitlement to COP. Thus, if leave is used intermittently with COP, the COP entitlement is not extended beyond 45 days. An employee who initially elects to use leave may request that it be changed to COP at a later date. The supervisor must take action to change the employee’s leave to COP as long as medical evidence is provided for the dates in question. HOW COP IS COUNTED In most instances COP begins the first day missed following a traumatic injury but can begin the day of injury if the incident occurred before the beginning of the shift. For instance if an employee is injured at 10:00 a.m. after a shift that began at 8:00 a.m. his COP would begin the day following the injury. However, if the employee is injured at 7:50 a.m. prior to the start of an 8:00 a.m. shift the first day of COP would be the date of the injury. In some cases employees may be able to return to work immediately but may have medical appointments or physical therapy. The absences due to these types of appointments will also be counted as a full day of COP. When the absence is continuous, weekends and holidays will also be counted as part of the 45 days allotted for COP. CONTROVERTING AND TERMINATING COP An agency’s objection to paying COP is called “controversion.” If an agency decides to controvert COP, the supervisor will indicate their intent to do so on the supervisors report of the CA-1 form and will submit detailed information to the OWCP to support the controversion. Continuation of Pay will be controverted by the employing agency for one of nine reasons listed below: • Disability is due to an occupational illness or disease • The employee serves without pay or nominal pay, is appointed to the staff of a former President, is selected pursuant to Chapter 121 of Title 28 and serves as a petit or grand juror, and is not otherwise an employee of the United States • The employee is not a citizen or resident of the United States or Canada • The injury occurred off the premises and the employee was not engaged in official duties. 10 • The injury was caused by employee’s willful misconduct or the employee intended to cause injury or death to himself or another, or the employee’s intoxication was the proximate cause of the injury • The injury was not reported on a form approved by OWCP (usually, Form CA-1) within 30 days of the date of injury • Work stoppage occurred more than 45 days after the injury • The employee first reported the injury after employment ended • Employee is enrolled in Civil Air Patrol, Peace Corps, Job Corps, Youth Conservation Corps, work-study program or other groups covered by special legislation In any of the above circumstances, the agency cannot authorize continuation of pay. However, if there is a question, OWCP will determine if the agency properly controverted COP. The agency may also terminate COP • If medical evidence to show the employee is disabled because of an employment injury is not received within 10 days from the date COP is claimed • When medical evidence is received from the attending physician stating the employee is no longer disabled for work • If an employee refuses a suitable job offer • If the employee’s scheduled employment comes to an end. WAGE LOSS Wage loss occurs when an employee is disabled from returning to work within the 45 days covered by continuation of pay. Loss of night differential or reduction to a lower grade when disability prevents an employee from returning to the position held prior to the injury would also be considered wage loss. When medical documentation indicates that an employee is going to miss workdays beyond the period covered by COP, the injured worker should file a CA-7 for compensation five working days prior to the expiration of COP. For reduction in grade or loss of differentials, the CA-7 should be filed as soon as the loss occurs. For instance, if an employee is a WG-10 Step 9 and is placed in a position that is a GS-7 Step 10 as a result of the injury, the employee can then file for wage loss for the difference when the loss occurs. 11 FORMS NEEDED FOR A TRAUMATIC INJURY CLAIM Form CA-1 Notice of Traumatic Injury and Claim for Continuation of Pay Submit within 30 days of injury. http://www.dol.gov/esa/regs/compliance/owcp/ca1.pdf CA-16 Authorization for Medical Treatment Issue within 48 hours of injury. Controlled form available from ICPA CA-20 Attending Physician’s Report Return to ICPA within 10 days of filing CA-1. http://www.dol.gov/esa/regs/compliance/owcp/ca20.pdf CA-7 Claim for Compensation File 5 working days prior to end of COP. http://www.dol.gov/esa/regs/compliance/owcp/ca7.pdf CA-7a Time Analysis Sheet File with CA-7. http://www.dol.gov/esa/regs/compliance/owcp/ca7a.pdf CA-7b Leave Buy Back Worksheet/Certification and Election Form Must be submitted with CA-7 and CA-7a when applying for Leave Buy Back. http://www.dol.gov/esa/regs/compliance/owcp/ca7b.pdf CA-17 Duty Status Report Submit every 2 weeks until recovery or until able to return to work. http://www.dol.gov/esa/regs/compliance/owcp/ca17.pdf Authorizes emergency medical treatment for a period of 60 days while OWCP processes your claim. Provides medical documentation needed for OWCP to process claims; required when submitting CA-7 claims. Purpose To provide written notice of the injury and file claim for compensation. Completed By Employee, page 1 Supervisor, pages 2 and 3 Witnesses should complete the bottom of page 1 or attach an additional sheet. ICPA, Occupational Health or Supervisor Physician must complete reverse side. Treating physician Claim for compensation beyond 45 day COP coverage; CA-20 must be attached. Form is also used to file for scheduled award; leave buy back or wage loss. Provides detailed listing of periods missed from work; must accompany CA-7 when applying for leave buy back or during intermittent periods. Worksheet used by the agency to determine amount of leave that will be repurchased as well as the amount owed by the employee and OWCP. Serves as election form once calculation is complete. Specifies restrictions that are imposed on the employee as a result of injury used to determine if accommodations can be made for light duty. Employee, page 1 ICPA, page 2 Employee ICPA DFAS ICPA Employee Supervisor, left column Physician, right column 12 CHAPTER 6: OCCUPATIONAL ILLNESS AND DISEASE NOTIFICATION REQUIREMENT Employees who suspect that they are suffering from an occupational illness should notify their supervisor as soon as they become aware of the condition, using form CA-2. The claimant is responsible for providing medical documentation, which shows a causal relationship between the condition and their place of work. Employees may file a claim for occupational disease for up to 3 years from the date of onset or the date they become aware of the work related condition. ADDITIONAL DOCUMENTATION REQUIRED Occupational disease claims also require additional documentation, which is identified on a checklist. Since there are eight different checklists to choose from, it is advisable for the supervisor to contact the ICPA to insure that the appropriate list is given to the employee. The employee should then be issued two copies of the checklist so that one may be given to their attending physician. Emphasis must be placed on the importance of providing as much of the requested information, in detail, as possible. The supervisor must review the statement provided by the claimant and provide written comments to OWCP. Supporting documentation to include reports from safety, industrial hygiene or the provost marshals office must also be provided to OWCP as well. EXCLUSIONS Claimants filing for occupational illness are not entitled to COP unless the condition is initially believed to be traumatic. Nor can CA-16 be issued except in rare cases and must be preauthorized by OWCP. CLAIMING WAGE LOSS COMPENSATION Once a claim for Occupational Illness or Disease is accepted, the employee can file for compensation for wage loss by submitting a CA-7 (Claim for Compensation). Supporting medical documentation, including a CA-20, must be submitted with the CA-7 claim that shows the employee was disabled from coming to work during the specified time, that the employee’s schedule was changed due to restrictions specific to the injury which resulted in wage loss or that she was receiving medical treatment. If an employee has returned to work but continues to receive medical treatment, the employee may file for compensation for wage loss for up to 4 hours per visit. CA-7 claims should be filed with a minimum of 10 hours claimed unless it is the final claim for compensation being made. For claims involving intermittent dates, a CA-7a (Time Analysis) form must accompany the CA-7 and the medical documentation must specifically support each date claimed. 13 FORMS NEEDED FOR OCCUPATIONAL DISEASE CLAIMS Form CA-2 Notice of Occupational Disease and Claim for Compensation http://www.dol.gov/esa/regs/compliance/owcp/ ca-2.pdf CA-35 Occupational Disease Checklists The ICPA will assist the employee with selection of the appropriate form: (a) general disease (b) hearing loss (c) asbestos (d) coronary/vascular (e) skin disease (f) pulmonary (not asbestos) (g) psychiatric (h) carpal tunnel http://www.dol.gov/esa/regs/compliance/owcp/ ca-35.pdf CA-20 Attending Physician’s Report Return to ICPA within 10 days of filing CA-1. http://www.dol.gov/esa/regs/compliance/owcp/ ca-20.pdf CA-7 Claim for Compensation File 5 working days prior to end of COP. http://www.dol.gov/esa/regs/compliance/owcp/ ca-7.pdf CA-7a Time Analysis Sheet File with CA-7. http://www.dol.gov/esa/regs/compliance/owcp/ ca-7a.pdf CA-7b Leave Buy Back Worksheet/Certification & Election Form Must be submitted with CA-7 and CA-7a when applying for Leave Buy Back. http://www.dol.gov/esa/regs/compliance/owcp/ ca-7b.pdf CA-17 Duty Status Report Submit every 2 weeks until recovery or until able to return to work. http://www.dol.gov/esa/regs/compliance/owcp/ ca-17.pdf Specifies restrictions that are imposed on the employee as a result of injury; used to determine if accommodations can be made for light duty. Supervisor, left column Physician, right column Claim for compensation due to periods of disability; CA-20 must be attached. Form is also used to file for scheduled award; leave buy back or wage loss. Provides detailed listing of periods missed from work; must accompany CA-7 when applying for leave buy back or during intermittent periods. Employee page 1 ICPA page 2 Provides medical documentation needed for OWCP to process claims; required when submitting CA-7 claims. Treating physician Provides checklists of documents needed to file claims for specific types of diseases. All items must be submitted. Purpose To provide written notice of the injury and file claim for compensation. Completed By Employee, page 1 Supervisor, pages 2 and 3 Witnesses should complete the bottom of page 1 or attach an additional sheet. Employee Supervisor Physician Employee ICPA Worksheet used by the agency to determine amount of leave that will be repurchased as well as the amount owed by the employee and OWCP. Serves as election form once calculation is complete. DFAS ICPA Employee 14 CHAPTER 7: RECURRENCE TYPES OF RECURRENCE There are two types of recurrence which an employee can file a claim for: • Recurrence of disability is a spontaneous return or increase of disability due to the previously accepted injury when there is no intervening cause for the increased disability other than the original injury itself. • Recurrence of a medical condition is the need for further medical attention as a result of the previously accepted injury when an employee has returned to duty and been released from medical treatment. This does not apply to those who have returned to duty without being fully released from treatment by their provider. Continuation of Pay applies to recurrence when the employee does not use all of their entitlement at the onset of the original injury and when the condition recurs before the end of 45 calendar days from the date of injury. For instance, if an employee uses 5 days of COP at the onset of the original injury, returns to work and then suffers a recurrence on the 30th day, the employee will be allotted 45 days to use the remaining 40 days of COP entitlement. NOTIFICATION REQUIREMENT Employees must file a CA-2a (Notice of Recurrence) to be eligible for wage loss and compensation for continued medical treatment of a previously accepted injury. The supervisor or ICPA must be notified by the employee as soon as possible when their condition worsens or returns. To complete notification, Sections A and C of the CA-2a must be filled out by the employee and Section B must be completed by either the employee’s supervisor or the Injury Compensation Program Administrator (ICPA) unless the claimant no longer works for the agency. Recurrence filed after employment has ended require the employee to complete their sections and send the form directly to OWCP. 15 FORMS NEEDED FOR CLAIMS OF RECURRENCE Form CA-2a Notice of Recurrence http://www.dol.gov/esa/regs/compliance/owcp/ca2a.pdf CA-20 Attending Physician’s Report Return to ICPA within 10 days of filing CA-1. http://www.dol.gov/esa/regs/compliance/owcp/ca20.pdf CA-7 Claim for Compensation File 5 working days prior to end of COP. http://www.dol.gov/esa/regs/compliance/owcp/ca7.pdf CA-7a Time Analysis Sheet File with CA-7. http://www.dol.gov/esa/regs/compliance/owcp/ca7a.pdf CA-7b Leave Buy Back Worksheet/Certification and Election Form Must be submitted with CA-7 and CA-7a when applying for Leave Buy Back. http://www.dol.gov/esa/regs/compliance/owcp/ca7b.pdf CA-17 Duty Status Report Submit every 2 weeks until recovery or until able to return to work. http://www.dol.gov/esa/regs/compliance/owcp/ca17.pdf Purpose To provide written notice of recurrent injury and file claim for compensation. Provides medical documentation needed for OWCP to process claims; required when submitting CA-7 claims. Completed By Employee, page 1 Supervisor, pages 2 and 3 Witnesses should complete the bottom of page 1 or attach an additional sheet. Treating physician Claim for compensation due to missed work. CA-20 must be attached. Form is also used to file for scheduled award; leave buy back or wage loss. Provides detailed listing of periods missed from work; must accompany CA-7 when applying for leave buy back or during intermittent periods. Worksheet used by the agency to determine amount of leave that will be repurchased as well as the amount owed by the employee and OWCP. Serves as election form once calculation is complete. Specifies restrictions that are imposed on the employee as a result of injury used to determine if accommodations can be made for light duty. Employee, page 1 ICPA, page 2 Employee ICPA DFAS ICPA Employee Supervisor, left column Physician, right column 16 CHAPTER 8: LEAVE BUY BACK On occasion, employees may use their own sick or annual leave to cover absences related to their injury or illness. Once an employee’s claim has been accepted by OWCP the employee may wish to have their leave restored. Since the employee was paid regular salary when the leave was used, steps have to be taken to undo the leave status and place the employee in an injury compensation status so that the time history with the agency will appear as a non-paid status for OWCP purposes. In order to accomplish this, a determination must be made as to how many hours of leave the employee is eligible to receive and the employee must pay the difference between the amounts received in their leave status versus what they receive for compensation from OWCP. This process is called a leave buy back. Employees request to buy back annual or sick leave by completing a CA-7 and a CA-7a. The CA-7 and CA-7a will be forwarded to Defense Finance and Accounting Service (DFAS) along with a CA-7b (Leave Buy Back Worksheet/Certification and Election) form. DFAS will calculate the amount owed by the employee according to the total hours being claimed and certify the CA7b. Once the certification has been completed the CA-7b will be returned to the ICPA who will have the employee make their election to accept or decline the leave buy back. There are many considerations to be made before an employee buys back leave. Before leave can be credited back to the employee, their pay status must be changed to a non-pay status for OWCP. Since the employee was in a pay status while using their leave certain deductions were made which are not covered while in a non-pay status such as contributions to the Thrift Savings Plan (TSP). Employees must be advised of the effect that leave buy back will have on them. No leave can be repurchased for time that an employee was eligible for COP. When disability does not extend for more than 14 days beyond the initial 45 days of eligibility for COP, there is a 3day waiting period that the employee will not be compensated for. When attempting to buy back leave, the 3 days must be converted to the non-pay status along with the other dates claimed even though the leave used cannot be repurchased for those dates. 17 FORMS NEEDED FOR LEAVE BUY BACK Purpose Provides medical documentation Return to ICPA within 10 days of filing needed for OWCP CA-1. to process claims; required when http://www.dol.gov/esa/regs/compliance/ submitting CA-7 claims. owcp/ca-20.pdf CA-7 Claim for Compensation File 5 working days prior to end of COP. http://www.dol.gov/esa/regs/compliance/ owcp/ca-7.pdf Claim for compensation due to periods of disability; CA-20 must be attached. Form is also used to file for scheduled award; leave buy back or wage loss. Provides detailed listing of periods missed from work; must accompany CA-7 when applying for leave buy back or during intermittent periods. Worksheet used by the agency to determine amount of leave that will be repurchased as well as the amount owed by the employee and OWCP. Serves as election form once calculation is complete. Form CA-20 Attending Physician’s Report Completed By Treating physician Employee, page 1 ICPA, page 2 CA-7a Time Analysis Sheet File with CA-7. http://www.dol.gov/esa/regs/compliance/ owcp/ca-7a.pdf Employee ICPA CA-7b Leave Buy Back Worksheet/Certification and Election Form Must be submitted with CA-7 and CA-7a when applying for Leave Buy Back. http://www.dol.gov/esa/regs/compliance/ owcp/ca-7b.pdf DFAS ICPA Employee 18 CHAPTER 9: EMPLOYEE RIGHTS AND RESPONSIBILITIES Federal employees have certain rights and responsibilities regarding work related injury or illness claims. • Employees are responsible for notifying their supervisor as soon as possible when an injury occurs. • Employees are entitled to file claims for what they perceive to be work related injuries or diseases. • For traumatic injury claims, employees are entitled to receive COP unless their claim for such is controverted for one of the nine reasons specified in Chapter 5 or if COP is stopped by the agency or OWCP for the employees failure to provide documentation, refusal to accept suitable job offers or scheduled termination of appointment to their federal position when the date was set prior to injury. • Employees are responsible for notifying physicians that light duty may be available and are expected to accept placement in suitable light duty positions when they are offered. Failure to accept a suitable job offer will result in termination of compensation benefits. • Employees are entitled to file claims for compensation when their disability extends beyond 45 calendar days from a traumatic injury, when work stops due to occupational disease. • Employees are entitled to file claims for scheduled awards for permanent impairment of specific members, functions or organs of the body. • Employees are responsible for providing truthful claims. Penalties for filing false claims are up to a $1,000.00 fine and no more than 5 years of imprisonment. • Employees have retention rights to return to their original position or an equivalent should they recover from their disability and become able to return to work within 1 year. 19 CHAPTER 10: SUPERVISOR’S RIGHTS AND RESPONSIBILITIES Supervisors also have rights and responsibilities to both the agency and to their employees: • Supervisors are responsible for completing and signing claim forms submitted to them by employees regardless of whether they agree with the claim or not. • Supervisors are responsible for notifying their command, their unit safety representative nd the ICPA when an injury occurs. • Supervisors have the right to controvert continuation of pay when they doubt the validity of the claim. • Supervisors are responsible for notifying the ICPA when there is reason to doubt the validity of any claim. • Supervisors are responsible for submitting claims to the ICPA for review in enough time for the documents to be forwarded to OWCP within 10 days of receiving notice. • Supervisors have the right to proceed with disciplinary action for violations related to the claims regardless of whether or not the condition has been accepted by OWCP. If an employee has been counseled several times for failure to wear personal protective equipment and is injured as a result, the supervisor can follow the normal course of progressive discipline. • Supervisors have the right to continue processing personnel actions that were already in progress at the time the injury or illness claim is filed. No personnel action should be stopped as a result of an injury claim. The ICPA should be notified when an employee files a claim in the midst of removal or disciplinary action. • Supervisors are responsible for ensuring that an SF-52 is processed when an employee is in a non-paid status for more than 80 hours. • Supervisors are responsible for ensuring that an employee’s timecard is correctly coded according to the guidelines above and that timecard corrections are made when errors are made. 20 Chapter 11: REIMBURSEMENT FOR OUT OF POCKET MEDICAL AND TRAVEL EXPENSES MEDICAL EXPENSES Once a claim has been accepted employees may file for reimbursement of medical expenses paid out of pocket, which includes co-pays, prescription medications, medical supplies or medical equipment purchased or rented. A separate OWCP-915 (Claim for Medical Reimbursement) must be filled out for each provider. Documentation required for pharmacy claims include a pharmacy billing form and proof of payment, which can be in the form of a receipt, cancelled check or credit card slip. For other medical expenses such as co-pays, an OWCP-1500 or OWCP-92 must be attached indicating the amount paid by the employee along with proof of payment. TRAVEL EXPENSES Travel expenses can also be claimed by completing an OWCP-957 (Medical Travel Refund Request). Travel must be completed by the shortest route possible. If the employee uses his personal vehicle he will be paid mileage at the current government rate at the time of service. Employees are also eligible for reimbursement if a taxi, bus or subway must be used. Prior authorization must be obtained in cases requiring extensive travel, lodging or an attendant to assist the employee. When no per diem is available, travel expenses will be paid based on actual expense. Original receipts must be submitted with the travel claim. 21 CHAPTER 12: MISCELLANEOUS PROVISIONS TIMEKEEPING Supervisors are responsible for ensuring that an injured employee’s timecards accurately reflect their absence due to a work related injury or illness. For traumatic injuries the timecard must be coded as LU for the date the injury occurs. If the employee chooses to use COP, an SF 71 (leave request) must be completed and the timecard shall be coded as LT. When the period of disability extends beyond 45 days employees may elect to use their annual or sick leave or go into a non-pay status due to the injury. If the non-pay status is elected, it shall be coded as KD on the timecard. BILL PAYMENT AND MEDICAL AUTHORIZATIONS Bills associated with work related injuries are paid by OWCP through the contractor, Affiliated Computer Services (ACS). In order for a physician or medical facility to receive payment they must first register with ACS. Their registration is free and it establishes an ID number that can be used for both payment and for issuing medical authorizations. Registration may be completed on-line at http://owcp.dol.acs-inc.com or by contacting ACS at 866-335-8319 and selecting Option 2. Medical authorization is required for procedures such as extensive testing and surgery. Requests for medical authorization are reviewed by ACS as well and should be submitted to them directly by the provider either on-line at http://owcp.dol.acs-inc.com, by calling 866-335-8319 or by completing the form, available on the web-site, and faxing it to 800-215-4901. Services which are required by OWCP to have authorization will not be covered without prior approval unless there is an emergency. ELECTRONIC DATA INTERCHANGE Agencies are required to file traumatic injury and occupational disease claims through the webbased Electronic Data Interchange (EDI). The purpose of the new system is to improve the timely filing of claims, to decrease the amount of time it takes to process the claim and issue a claim number. Presently many of the claims are being submitted via EDI by the ICPA rather than through supervisors. In the near future, supervisors will be provided training and will be expected to submit claims for their employees through the electronic system. The information provided gives a brief overview of how the system works. To file a claim electronically a supervisor must go into the web-site below and enter the supervisory view. He may have the employee present while the form is filled out or the supervisor may have the employee fill out the paper copy so that the data can be transferred to the electronic form. The supervisor must follow the instructions on each screen until he reaches the end. The program will prompt the supervisor to correct all errors, print the claim and submit it. The submit option will not be available until the claim has been printed. Employees must view the claim and sign it before it is submitted. They must also be provided a copy of the final claim. Once it has been submitted, the claim will be routed to the ICPA who will ensure that all pertinent information is on the claim, input the required codes and foward it to OWCP through EDI. The supervisor must forward a copy of the signed claim to the ICPA and keep a copy for his records. The EDI is located at: https://edisup.cpms.osd.mil/static_java_edi_sup.html 22 CHAPTER 13: FREQUENTLY ASKED QUESTIONS The questions and answers below were taken from the Department of Labor’s web site and are reprinted below for your convenience. 1. Does the FECA cover a pre-existing medical condition that is aggravated by factors of employment? YES. Diseases and illnesses aggravated, accelerated or precipitated by the employment are covered. The employee must submit medical and factual evidence showing that the employment aggravated, accelerated, or precipitated the medical condition. 2. Is it necessary to report all injuries that occur at work, even minor ones such as a cut finger or bumped knee? All injuries should be reported when they occur, since a minor injury sometimes develops into a more serious condition. Benefits cannot be paid unless an injury is reported. 3. If an employee has a work-related injury and also suffers damage to personal property, such as clothing, can the employee be paid for such loss? The FECA does not provide for reimbursement for loss of personal property. The employee may claim such reimbursement from his or her employer under the Military and Civilian Personal Property Act of 1964, 31 U.S.C. 240. 4. Does an employee need an attorney or other representative to file or pursue a claim for compensation? NO. However, the employee may obtain the services of an attorney or other representative if desired. A Federal employee may not serve as a representative unless he or she is an immediate family member of the injured worker or is acting in his or her official capacity as a union representative. An OWCP employee may not act as a representative under any circumstances. The employee must advise OWCP in writing of the name of the representative. No special form is needed, but the employee must sign the statement. 5. How much does compensation coverage cost a Federal employee? NOTHING. Federal civilian employees are covered by virtue of their employment status. 6. Are there penalties for filing a false claim? YES. Federal law (18 U.S.C. 1920) provides: Whoever knowingly and willfully falsifies, conceals, or covers up a material fact, or makes a false, fictitious, or fraudulent statement or representation, or makes or uses a false statement or report knowing the same to contain any false, fictitious, or fraudulent statement or entry in connection with the application for or receipt of compensation or other benefit or payment under Subchapter I or III of Chapter 81 of Title 5, shall be guilty of perjury, and on conviction thereof shall be punished by a fine under this title, or by imprisonment for not more than 5 years, or both; but if the amount of the benefits falsely obtained does not exceed $1,000, such person shall be punished by a fine under this title, or by imprisonment for not more than 1 year, or both. 23 7. How does an employee notify OWCP of a change of address? The employee must advise the OWCP district office of any change of address in writing. No special form is needed, but the statement must be signed. 8. What can an employee do if his or her supervisor refuses to accept a notice of injury, illness or death? The employee should notify OWCP of the refusal. Federal law provides in 18 U.S.C. 1922 that: Whoever, being an officer or employee of the United States charged with the responsibility for making the reports of the immediate superior specified by Section 8120 of Title 5, willfully fails, neglects, or refuses to make any of the reports, or knowingly files a false report, or induces, compels, or directs an injured employee to forego filing of any claim for compensation or other benefits provided under Subchapter I of Chapter 81 of Title 5 or any extension or application thereof, or willfully retains any notice, report, claim, or paper which is required to be filed under that subchapter or any extension or application thereof, or regulations prescribed thereunder, shall be fined under this title or imprisoned not more than one year, or both. 9. Is an injury that occurs during work-related recreational activities considered to be in performance of duty? Injuries that occur during recreation which the employee is required to perform as a part of training or assigned duties, or which occur while the employee is in pay status, are considered to be in performance of duty for compensation purposes. Injuries that occur during informal recreation on the employer’s premises (for instance, jogging) may also be covered, as may injuries that occur while an employee is engaged in activities approved as part of an individual plan developed under a formal physical fitness program managed by the employer. Injuries that occur during informal recreation off the employer’s premises (such as playing on an employer-sponsored baseball team) may also be covered. The employer must explain what benefit it derived from the employee’s participation, the extent to which the employer sponsored or directed the activity, and whether the employee’s participation was required or not. 10. Is an employee considered to be in performance of duty while going to and from work? NO. Employees are not generally covered by the FECA for injuries that occur before they reach the employer’s premises or after they have left it. However, coverage may be extended when the employer provides transportation to and from work, when the employee is required to travel during a curfew or an emergency, or when the employee is required to use his or her automobile during the workday. 11. Is an employee considered to be in performance of duty 24 hours a day while in travel status? 24 An employee in travel status is covered 24 hours a day for all activities incidental to the work assignment. Such activities include obtaining meals, using the hotel room, and traveling between the hotel and the work site. They usually do not include recreational or sightseeing trips. 12. Would I be eligible for worker’s compensation benefits if I got hurt while exercising during lunch or just before or after the start of my shift? YES. Activities which are reasonably associated with employment would be eligible for coverage, however, the time during which you were injured would be taken into consideration. Most injuries are only eligible for coverage for a reasonable period of time prior to or after the start of the shift which is usually about 30 minutes. As with all claims, the facts surrounding the injury must be presented to OWCP who makes the final determination of what benefits an employee is eligible for. If you are working out at the gym during lunch or just before or after your shift you may be eligible for worker’s compensation benefits. 13. What if I get hurt while having lunch in the break room? Injuries which occur while engaging in an activity which is reasonably associated with employment including facilities for the employee’s comfort, health and convenience as well as eating meals and snacks provided on the premises, are eligible for coverage. 14. Can the injured worker choose the physician who will provide treatment? YES. An injured worker is entitled to a first choice of physician or facility for treatment of an injury. The provider must meet the definition of “physician” under the FECA. A physician working for or under contract to the employer may examine the employee in accordance with OPM regulations. However, the employee’s choice of physician must be honored, and treatment by the employee’s physician must not be delayed. 15. What is the definition of “physician” under the FECA? The term “physician” includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, osteopathic practitioners, and chiropractors within the scope of their practice as defined by State law. However, the services of chiropractors may be reimbursed only for treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist, except that a chiropractor may also provide services in the nature of physical therapy under the direction of a physician. By regulation, the term “qualified physician” does not include those individuals whose licenses to practice medicine have been suspended or revoked by a state licensing or regulatory authority or who have been excluded from payment under the FECA. 16. Will OWCP pay the entire amount of the medical bill, or is there a maximum limit? OWCP uses a schedule of maximum allowable medical charges. This schedule applies to charges for medical services rendered on and after June 9, 1986, by physicians, surgeons, podiatrists, clinical psychologists, optometrists, chiropractors, osteopathic practitioners, physicians’ assistants, and therapists. The fee schedule includes those services rendered in a hospital or nursing home setting, and to outpatient hospital services. It also applies to inpatient hospital services and pharmacy charges after January 4, 1999. However, nursing home charges are not subject to a fee schedule. 25 The employee does not have to pay the difference between the maximum charge set by the schedule and the charge made by the provider. 17. If an employee pays for authorized treatment or medication for a work-related injury, can he or she obtain reimbursement? YES. For medical, surgical, and dental services, the employee should use Form HCFA-1500, (American Medical Association Standard Health Insurance Claim Form), or OWCP-1500. The OWCP 1500 is the same as the HFCA 1500 except it includes instructions for filing with the OWCP. The provider must sign the form. For pharmacy expenses, the employee should use the Universal Claim Form, to include the name of the drug, name of prescribing physician and the date the prescription was filled. The employee must also complete Form CA-915, (Claimant Medical Reimbursement Form), and submit a copy with each Form HCFA-1500, OWCP-1500, or Universal Claim Form. Claims for hospital charges must be submitted on Form UB-92. Along with the proper forms, the employee should submit proof of payment. OWCP will accept signed statements by providers, a mechanical stamp showing receipt of payment, photocopies of canceled checks (both front and back), or a copy of a credit card receipt. Bills and requests for reimbursement must be sent to OWCP within a year after the end of the calendar year in which the expense was incurred or the service was provided, or within a year after the end of the calendar year in which the treated condition was first accepted as compensable by OWCP. For example, if the employee was treated in 1998 and OWCP accepted the claim in 1998, OWCP will process bills for that treatment if they are submitted by December 31, 1999. However, if the employee was treated in 1998 and OWCP accepted the claim in 1999, the employee would have until December 31, 2000 to submit bills. 18. Will an employee’s health benefit plan pay medical expenses resulting from workrelated injury or disease? Health benefit plans exclude work-related injuries, and a plan will not pay medical expenses if it is aware that a worker’s compensation injury is involved. If the plan pays for medical expenses that are later determined to be work-related, OWCP will reimburse the plan upon submittal of copies of the medical bills. 19. Can an employee change physicians? An employee who wishes to change physicians after the first choice must contact OWCP in writing for approval and include the reasons for requesting the change. Otherwise, the employee may have to bear the cost of unauthorized medical care. 20. Does the employer have the authority to accept or deny a claim? NO. Only OWCP may make this decision. While the employer pays or withholds COP, this action is subject to review by OWCP in every case. 21. How is the employee advised when a case has been accepted? 26 In very simple cases, the employee receives a postcard advising that medical expenses up to a set amount will be paid without further information from the employee. In most other cases, the employee receives a letter stating the injury-related medical conditions and explaining how to claim further benefits. 22. How is the employee advised when a case has been denied? A formal decision is sent to the employee. The decision states the specific reason for denying the case and discusses the evidence that led to the decision. Copies of the decision are sent to the employer and to the representative, if any. 23. If an individual disagrees with a formal decision of OWCP, what appeal rights are available? OWCP encloses a description of appeal rights with each formal decision. These rights include: (a) An oral hearing before an OWCP representative. The individual claiming benefits can testify and present written evidence. The hearing is held at a location near the individual’s home. He or she may have a representative at the hearing (see question A-9), but is not required to do so. (b) A review of the written record by an OWCP representative. The individual claiming benefits will not be asked to attend or testify, but he or she may submit written evidence. (c) Reconsideration by district office staff who were not involved in making the contested decision. The request must clearly state the grounds for requesting reconsideration, and it must include evidence not submitted before or a legal argument not made before. (d) Review by the Employees’ Compensation Appeals Board (ECAB). The ECAB is part of the U.S. Department of Labor but separate from OWCP. Review by the ECAB is limited to the evidence of record, and no new evidence may be submitted. The individual claiming benefits may be represented by an attorney or by any other person authorized by that individual. The ECAB must approve any fee for such representation. 24. If an individual disagrees with the decision reached on appeal, can he or she obtain review through a State or Federal court system? NO. The methods of appeal are limited to those described above. 27 CHAPTER 14: SOME HELPFUL RESOURCES DoD 1400.25-M, Subchapter 810, Injury Compensation http://www.cpms.osd.mil/cpm/docs/M1400810.pdf OPM Booklet: Work Related Injuries and Fatalities: What You and Your Family Need to Know http://www.hr.dla.mil/hr/library/pdf/owcp.pdf Federal Employee Compensation Act http://nt5.scbbs.com/cgi-bin/om_isapi.dll?clientID=287498&infobase=feca-act. nfo&softpage=PL_frame Code of Federal Regulations: Federal Employees Compensation Act http://www.hr.dla.mil/hr/bnfts/owcp/1999 CFR Title 20, Volume 1.htm Occupational Disease Checklists http://nt5.scbbs.com/cgibin/om_isapi.dll?clientID=287333&infobase=agencyhb.nfo&jump= Appendix%20C&softpage=PL_frame Injury Compensation for Federal Employees http://www.dol.gov/cgi-bin/leave-dol.asp?exiturl=http://nt5.scbbs.com/cgi-bin/om_isapi. dll^Q^infobase=agencyhb.nfo|softpage=PL_frame&exitTitle=Injury_Compensation_for_Federal_Employees,_Pub._CA-810 Injury Compensational Tutorials for Employees and Supervisors http://www.cpms.osd.mil/icuc/icuc.htm 28 29