The Role of Medical Personnel in OWCP Claims
Knee & Hip Arthritis is the Silent Occupational Disease No One Talks About
Medical Personnel and Their Roles
Attending Physicians
- You have a right to pick your doctors (Attending Physicians), including referral to consulting physicians, they are your “attending physicians”.
- Reports of an attending physician, evidence of laboratory findings, x-ray diagnostic reports, and the detailed medical notes of the attending physician have great weight.
- When the attending physician selected refers you to a specialist for further medical care, you do not need approval from OWCP. In all other instances, you must submit a written request to OWCP with his or her desiring a change of physician.
- The original medical report must be signed by a physician and submitted to OWCP as soon as possible after medical examination or treatment by an employee or physician
- In all cases of serious injury or disease, especially those requiring hospital treatment or prolonged case, OWCP will request detailed narrative reports from the attending physician at periodic intervals. The physician will be asked to provide these factors and the causal relationship.
- Examination – means an actual examination of the employee not just a review of the record.
- If there is a difference of opinion between the attending physician and the government’s physician, a third physician should be brought in to complete a separate examination.
- Physical exam takes precedence over the non-physical exam.
- If you want to change providers, you must request it in writing.
Physician’s Assistant
- A medical report signed by a PA must be signed by an MD to give probative value. PA reports need to be signed by MD.
- If an audiogram is prepared by an audiologist, it must be certified by a physician as accurate before it is used as a loss of percentage of hearing.
District Medical Director (DMD)
- DMD is an administrator who performs oversight functions of the district office’s medical benefits program.
- The DMD maintains a liaison with the medical community, provides training, and identifies and values credentials.
- The DMD does not do exams except for the evaluation of claimants who seek a schedule award for disfigurement of the face, head, or neck.
District Medical Advisor’s Role (DMA)
- The DMA’s role is limited to review of the case record. The DMA has two broad medical function;
- To evaluate the medical evidence and the rendering of medical opinions in the DMA’s own right. In this capacity, the DMA may advise whether a newly claimed condition is employment-related, whether the length of disability seems appropriate or whether the recommended procedure or treatment is useful.
- The DMA is involved in the interpretations and clarifications of other physician’s reports. Reviews for schedule awards.
- DMA has no authority to decide facts in the case – however DMA can give an opinion that based on facts, that the injury may have occurred.
- DMA may not resolve a conflict in medical evidence. Except in schedule award.
- Weight of DMA’s opinion – DMA may create a conflict in medical opinions necessitating a referee medical evaluation – DMA must provide a well-rationalized medical opinion to create a true conflict.
- The attending physician is in a better position to provide a report and should take precedence over DMA.
Second Opinion Specialist
- Usually obtained by OWCP. A 2nd opinion specialist provides an examination, review diagnostic testing and provide a rationalized medical opinion in a detailed and comprehensive report.
- In an occupational disease case, a 2nd is always utilized and for elective surgery
- Emergency surgery is limited to saving a life or protecting a limb.
- Federal law authorizes OWCP to require an employee who claims a disability, as a result of an employment injury, to undergo such physical exams as it deems necessary.
- Second Opinion Specialist should not be used to resolve a conflict.
- The exams are required under certain procedures with OWCP for both traumatic and occupational.
- Second opinion exam should be a complete in-person evaluation.
- Second Opinion Report includes a complete review of all medical evidence, including estimate of full recovery
Referee Specialist
- When there is a conflict in medical evidence between 2nd Opinion Specialist and the attending physician, the case must be sent to the referee specialist to obtain an Independent Medical Exam (IME). Usually specialist in that field.
Psychologist
- Psychologists must be licensed and certified in the state, have two years of experience and 1-year post-doctorate
Staff Nurse
- OWCP can ask nurse (Field Nurse- FN) to call your physician and request information needed.
- FN are hired to assist in the rehab process and get the workers back to work. Assist physician in treating worker and getting them back to work.
- When Physician determines the IW can work 4 hours, FN contacts OWCP.
- FN will work with Employing Agency (EA) to make sure the demands of the job are within physical requirements outlined by your doctor.
- FN can recommend 2nd opinion, refer to vocab rehab, and change of physician.
- You must cooperate with the FN.
Chiropractors
- Chiro’s opinion can only be used to the extent that reimbursable services are limited to manual manipulation of the spine to correct a subluxation as demonstrated by an X-ray.
- A chiropractor is not able to complete schedule awards examinations.
Expert’s Weight on Medical Evidence
- The source of the medical report is extremely important. Physicians who have training in a specific area will be given more weight. The more specialized, the more weight.
- It is not necessary that the medical evidence be so conclusive as to suggest causal connection beyond all possible doubt in the mind of the medical scientist. The evidence required is only necessary to convince the adjudicator that the conclusion drawn is rational, sound, and logical.
- A decision on whether an employee is physically able to do the work is a question decided by medical evidence.
Mandatory Attendance for Medical Exams
- You must report for Second Opinions or Referee Specialists.
- If you refuse, your right to benefits stops until the obstruction is removed. If you change your mind and go, benefits will start up again.
- The Office must provide the claimant 14 days notice before they suspend benefits for failure to attend an exam.
- You need a valid reason not to attend a medical exam.
Conflicts of Medical Evidence – IME
- When both board-certified attending physician and 2nd opinion have a conflict, OWCP needs an IME to resolve the conflict.
- When the IME is done by a Referee Specialist, the probative value of the referee specialist report is usually greater and will normally constitute the weight of the evidence.
- IME must provide a statement that explains the resolution of a medical conflict.