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Division of Federal Employees' Compensation (DFEC)

Procedure Manual

FECA Part 7

LIST of CHAPTERS

7-0100

Introduction to Nurse Intervention

7-0300

Continuation of Pay (COP) Nurses

 

 


Chapter 7-0100, Introduction to Nurse Intervention

Paragraph and Subject

Date

Trans. No.

Table of Contents

07/12

12-09

1. OWCP Objectives

07/12

12-09

2. Scope

07/12

12-09

3. Purpose

07/12

12-09

4. National Office Nurse Consultant

07/12

12-09

5. District Office Staff Nurses

07/12

12-09

6. Continuation of Pay (COP) Nurses

07/12

12-09

7. Field Nurses

07/12

12-09

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1. OWCP Objectives. The Office of Workers' Compensation Programs (OWCP) is committed to seeing that benefits for compensation and medical services are appropriately and timely provided. OWCP is also committed to assisting injured workers in obtaining a successful medical recovery and minimizing the period of disability from work. Management of disability claims begins as soon as a new claim is received indicating that the employee has lost time from work as a result of the injury or is disabled from his or her date of injury position.

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2. Scope. This chapter defines the objectives and purpose of nurse intervention and the types of nurses involved in the OWCP nurse intervention program. Federal Employees' Compensation Act (FECA) Procedure Manual (PM) 2-0600 discusses disability management from a CE's perspective, and FECA PM 2-0811 discusses the role of nurse case management.

Services of field nurses are authorized by 5 U.S.C. 8103; 20 C.F.R. §10.310(a) specifically references that "OWCP may also utilize the services of a field nurse to facilitate and coordinate medical care for the employee."

Disclosure of information to contract nurses is authorized by routine use "e" of DOL/GOVT-1, which permits disclosure: To physicians, pharmacies, and other health care providers for their use in treating the claimant, in conducting an examination or preparing an evaluation on behalf of OWCP, and for other purposes relating to the medical management of the claim, including evaluation of and payment for charges for medical and related services and supplies.

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3. Purpose. To further the objectives noted above, OWCP created the Nurse Intervention Program and incorporated it into the Quality Case Management (QCM) portion of the Disability Management process. QCM is a case management approach which has as its primary goal the medical recovery and reemployment of injured workers who are in the beginning stages of disability. The objectives of QCM are to take a series of purposeful actions to obtain medical care in a timely manner, to obtain timely work tolerance limitations, and to prevent cases from reaching the long-term disability roll. QCM is an initiative to intervene with injured workers, employing agencies (EA) and medical providers as early as possible in the recovery process to assist in the facilitation of medical treatment plans and arrange for appropriate reemployment.

Incorporating nurse intervention services into the QCM disability management process, and involving nurses in the early stages of disability cases, facilitates expedited medical care and recovery and can result in shortening the length of disability from work. Although the Claims Examiner (CE) ultimately remains responsible for the case management activities and overall direction of the case, QCM consists of more than just CE intervention. The best outcomes stem from an active team approach where the CE, the nurse, the EA, the claimant, and the medical providers use all available tools to facilitate medical recovery and a successful return to work. As a result, nurse intervention is an integral part of the overall disability management of a claim.

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4. National Office Nurse Consultant. The National Office Nurse Consultant (NONC) serves as the National Coordinator for the OWCP nurse intervention program. The NONC is responsible for overseeing the appropriate application of medical standards to the OWCP nurse program; planning and developing methods for the assessment of the OWCP nurse programs; serving as a resource for the District Office Staff Nurses; and, as needed, implementing improvements based upon the analysis of internal OWCP data and examination of outside trends in the workers' compensation field.

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5. District Office Staff Nurses. Each district office retains the services of a Staff Nurse (SN) to administer the policies and procedures of the OWCP nurse intervention program. The SN coordinates the assignment of contract nurses for specific cases; monitors contract nurses' performance in correlation to both the contract specifications and the quality of services provided; reviews nurse reports for completeness and timeliness prior to authorizing payment of bills; and communicates with the CE as needed with regard to issues that arise during the nurse intervention phase.

As mentioned above, the QCM disability management process is a collaborative effort. While the CE maintains authority over the case management actions, communication between the SN, CE, and contract nurse is essential to reaching the goals and objectives established for any given disability case. The SN is in a unique position to timely identify and bring to the CE's attention medical issues or obstacles that need prompt attention. In addition, active involvement of the SN facilitates the interactions and communications between the CE and contract nurse.

A CE or other district office staff member may consult with the SN in order to assess medical treatments and protocols; discuss whether a particular treatment or surgery is appropriate; or seek recommendations on alternative avenues for continued treatment. The SN is also able to provide clarification and explanation related to medical issues or treatment requests that may be unfamiliar to the CE.

The SN also serves as a liaison and resource for EA representatives. The EA may contact the SN directly regarding any concerns or questions it may have about a specific contract nurse, nurse assignment, or the OWCP nurse intervention program in general. The SN may also participate in agency training sessions offered by the district office.

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6. Continuation of Pay (COP) Nurses. COP Nurses (CN) are contracted nurses assigned in traumatic injury cases where the injured worker has immediate disability and has not returned to work within 7 days following the date of work stoppage (this information is taken from the data contained on the Form CA-1). The CN enables the district offices to identify cases in need of prompt adjudication and assists the CEs in prioritizing their adjudication efforts. The CNs have a role only during the COP period and are strictly triage nurses whose work is performed telephonically. (CNs are not assigned in occupational disease cases.)

Within 7 days of case assignment, the CN should contact the claimant, the EA and the treating physician. At a minimum, the CN should obtain a history of the injury from the claimant; confirm the work status with the EA and ascertain whether work accommodations are available; and contact the physician's office to obtain a history of the medical treatment provided and the expected treatment plan. This information is then used by the CE to make decisions about the best case management path for that particular case, which may include expedited adjudication of the case and referral for Field Nurse (FN) assignment.

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7. Field Nurses. The FN is a contracted registered nurse who assists in the management of disability claims in a number of ways. FN services are a valuable tool for assisting in the claimant's recovery process by coordinating medical care, facilitating a safe and timely return to work, and aiding the CE in moving a disability case towards resolution. The FN's contact is generally in person; however, in some instances the activity may be only telephonic in nature.

Early referral for FN intervention services is critical to ensuring successful disability management. FN assignment should occur as soon as possible after the injury occurs and the claim has been approved for a work-related injury. FN assignment should occur if the claimant has not returned to work and may also occur if the claimant has returned to work but remains disabled from performing his or her date of injury position. An FN is usually initially assigned to a case for 120 days, but this assignment period may be extended.

Specific FN activities may include the following: making assessments of the initial extent of the injury; coordinating treatment necessary for recovery; communicating return-to-work expectations; attending the claimant's medical appointments to facilitate communication about return to work and ease any authorization difficulties the claimant may be encountering; identifying possible barriers to the claimant's return to work and then developing a plan of action with the CE to resolve the identified barriers; making recommendations for vocational rehabilitation; and acting as a liaison between the CE, claimant, EA, and medical providers.

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Chapter 7-0300, Continuation of Pay (COP) Nurses

Paragraph and Subject

Date

Trans. No.

Table of Contents

08/12

12-11

1. Background

08/12

12-11

2. Purpose and Scope

08/12

12-11

3. Introduction

08/12

12-11

4. Identification of Cases for Assignment of COP Nurse

08/12

12-11

5. COP Nurse Intervention Actions

08/12

12-11

6. COP Nurse Reimbursement

08/12

12-11

7. Claims Examiner Actions Upon COP Nurse Closure

08/12

12-11

8. COP Nurse Closure Codes

08/12

12-11

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1. Background. The Office of Workers' Compensation Programs (OWCP) has been using Continuation of Pay (COP) Nurses for many years. Federal Employees' Compensation Act (FECA) Bulletin 00-15 (COP Nurse Intervention), issued September 18, 2000, introduced the implementation of the COP Nurse (CN) intervention program as an effort to provide early identification and triaging of certain traumatic injury cases involving disability from work during the 45-day COP period. By utilizing early intervention of the CN process, there has been a favorable impact upon expedited adjudication of traumatic injury disability cases, thus allowing early disability management interventions to assist with medical recovery and return to work (RTW) efforts.

Since the release of FECA Bulletin 00-15, subsequent updates have been made to the CN intervention program to facilitate quicker assignments to the CN and more efficient follow-up actions by the OWCP claims staff. FECA Bulletin 01-09 (COP Nurse Intervention), issued February 5, 2001, incorporated changes to the CN intervention program which further enabled the district offices to identify traumatic injury cases in need of prompt adjudication and assisted Claims Examiners (CE) in prioritizing their adjudication efforts. Specific triage codes were created whereby the CN was able to identify the disability status of a claimant upon closure of his/her intervention activities. These CN disability triage closure codes, along with the automated updates and processes to both the CN's web-based "home page" and the district office's case management system, assisted the CEs in identifying and prioritizing the adjudication of these cases. In addition, case management reports were revised so that OWCP claims staff were better able to track and monitor traumatic injury cases that included the prioritized triaged closure coding.

FECA Bulletin 10-04 (COP (Continuation of Pay) Nurse Intervention Process Updates), issued September 10, 2010, was the latest update to the CN intervention process. This Bulletin provided guidance to OWCP claims staff, the district office Staff Nurse (SN), and employing agencies (EA) regarding significant updates and revisions to the CN intervention program. Those updates and revisions included earlier CN case eligibility, quicker CN assignments, specific expectations for CN intervention activities, shorter timeframes for CN activities and reporting, allowance of CN access to view certain applications within OWCP's case management system, and expansion of CN closure codes. The EAs' access to view case statuses through the Agency Query System (AQS) was updated to allow them to see which cases were assigned to a CN, and upon CN closure, they were able to see the CN closure status and date. EAs were also provided information regarding the preferred method of prompt reporting of an injured worker's RTW via electronic submission of Form CA-3. Finally, OWCP claims staff was advised of necessary case management actions in regard to CN assignments, CN closures, and notices of RTW. Additional reports were made available to assist the OWCP claims staff to more effectively manage cases during the CN intervention process.

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2. Purpose and Scope. This chapter defines the objectives and purpose of the CN intervention program and the roles and responsibilities of the stakeholders involved.

FECA Procedure Manual (PM) 2-0600 (Disability Management) discusses disability management from a CE's perspective, and FECA PM 2-0811 (Nurse Case Management) discusses the role of nurse intervention in the Disability Management process.

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3. Introduction. Involving nurses in the early stages of disability cases (even prior to case adjudication) facilitates expedited medical care and recovery and can result in shortening the length of disability from work.

The CN is a registered nurse who is assigned to traumatic injury cases where the injured worker has immediate time loss and has not returned to work within seven (7) days following the date of work stoppage. The CN assignment occurs prior to case adjudication. The CN is strictly a triage nurse who performs all work telephonically.

The information obtained by the CN is then used to make decisions about the best path for that particular case. In particular, the information provided by the CN should assist the CE by triaging the severity of the injury and/or disability. This most often leads to the CE being able to expedite adjudication of traumatic injury disability cases and subsequently determine whether a referral for Field Nurse intervention would be beneficial to assist with the medical recovery and RTW efforts integral to the success of early disability case management.

Note: COP is not payable in occupational disease cases, and occupational disease cases are ineligible for CN assignments.

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4. Identification of Cases for Assignment of COP Nurse.

a. Based on the data entered when a traumatic injury case is created from Form CA-1 (specifically, the date the injured worker 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 injured worker stopped work at least 7 days ago;

(3) The injured worker stopped work less than 31 days ago;

(4) The injured worker has not returned to work;

(5) The injured worker 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 pay status is either Unreviewed (UN) or Under Development (UD).

b. COP cases are automatically referred to the SN for assignment through the office's case management system based on the criteria noted above. 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 occurs even though the case has not yet been formally accepted.

c. CN assignments are made electronically through the office's case management system, and necessary information is accessed by the CN via remote access to select applications of the office's case management system. The CN can view his/her open cases, cases requiring action, and new assignments.

d. If the EA reports a RTW after the Form CA-1 has been submitted but prior to the CN assignment, the RTW date should be immediately updated in OWCP's case management system so that a CN is not assigned. If a RTW is reported after the CN assignment but before the CN closure, the RTW date should be immediately updated in OWCP's case management system so that CN intervention can be closed (whether the CN has taken any actions or not).

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5. COP Nurse Intervention Actions. Although CN intervention is not extensive during the COP period, the medical knowledge and experience of a CN assists with the identification of cases that require more extensive intervention due to the severity of the injuries, contemplated surgical intervention, or lost time from work.

a. In order to effectively triage the case, within 7 days of case assignment the CN should:

(1) Contact the injured worker 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 injured worker'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 verbal history of treatment, the expected treatment plan, and, if available, the date of the injured worker'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 be approved. The CN should also advise the physician's office whether light duty job 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. The CN should obtain the necessary information, as outlined above, and submit a closure report within 7 days. However, if the CN determines that the injured worker will be returning to work within the following week, and the specific contact information supporting a definitive RTW date has been has been entered into the case management system, 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 closure should still occur no later than 14 days after assignment.

c. Once the CN has gathered the information, he/she enters it into the case management system. These entries are then automatically part of the COP Nurse Report. The CN should also include any other relevant information pertaining to possible issues or concerns regarding the recovery process or potential barriers to the RTW effort. The CN should make a specific recommendation pertaining to whether a Field Nurse assignment would be beneficial. The CN closure report should contain the RTW status and provide a recommendation regarding early intervention and assignment to a Field Nurse.

d. When the CN closes the case, he/she should also confirm appropriate handling/destruction of case file records.

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6. COP Nurse Reimbursement. When the CN closes a case, the SN reviews the closure for appropriateness and accuracy. Once the SN has approved the closure, the COP Nurse Report is automatically generated for processing into the electronic case file, and the bill is processed electronically and submitted for payment to the central bill payment processing facility.

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7. Claims Examiner Action Upon COP Nurse Closure. After the SN approves the CN closure, the CN report will be viewable in the case file.

a. If the CN closes the case and the injured worker has not returned to work in a full-time capacity, the case should be reviewed for expedited adjudication action. The information provided in the CN closure report may also be used to determine whether a referral for Field Nurse intervention is needed.

b. For an administratively closed case, any CN closure code that denotes less than a full-time RTW will "flip" the case to UN status so that it can be adjudicated. Since Field Nurses are not assigned to unadjudicated cases, the CE should attempt to expedite the adjudication process in these cases where the claimant has not achieved a RTW in a full-time capacity. If the case cannot be accepted upon first review, prompt development action should be undertaken. The claimant will be afforded 30 days to submit necessary evidence, but the claim should be monitored during that 30-day period so that it can be accepted as soon as the proper supporting documentation is received.

c. If a traumatic injury case has been accepted, and the claimant has not returned to work in a full-time capacity, the case should be referred for Field Nurse assignment promptly after acceptance. This referral should occur even if the COP period has not elapsed. In addition, a Field Nurse referral should also be considered if the claimant has returned to work full time but in a light-duty status.

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8. COP Nurse Closure Codes. Every case assigned to a CN is closed with a COP Nurse Closure Code in the case management system.

COP Nurse Closure codes are outlined below:

9A:

COP Case Closed-Case Accepted

9B:

COP Case Closed by CE with FT/LD RTW

9C:

COP Case Closed by CE with FT/RD RTW

9D:

COP Case Closed-Case Denied

9E:

COP Case Closed by CE with PT RTW

9F:

COP Case Closed Using CA-3 with FT/RD RTW

9G:

COP Case Closed Using CA-3 with FT/LD RTW

9H:

COP Case Closed-Emergency Hospitalization

9K:

COP Case Closed Using CA-3 with PT RTW

9L:

COP Case Closed by Nurse with FT/LD RTW

9N:

COP Case Closed-No RTW

9O:

COP Case Closed-Claimant Not Cooperating

9P:

COP Case Closed by Nurse with PT RTW

9R:

COP Case Closed by Nurse with FT/RD RTW

9S:

COP Case Closed-Surgery Imminent

9T:

COP Case Closed-Catastrophic Case

9U:

COP Case Closed-RTW Unknown

9X:

COP Case Closed-Stopped Work >45 days

9Y:

COP Case Closed Using CA-3-RTW without status


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