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Division of Federal Employees' Compensation (DFEC)

Field Nurse Handbook

Part 7


Part 7 - Facilitating Medical Interventions

Paragraph and Subject

Date

FNHB Trans. No.

Table of Contents

09/13

13-01

1. Overview

09/13

13-01

2. Treating Physician/Medical Provider(s)

09/13

13-01

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1. Overview. The Field Nurse's (FN's) ability to establish collaborative and cooperative working relationships with the medical provider community places them in a unique position to effectively facilitate appropriate medical intervention(s) in a timely manner. However, sometimes there are medical management issues that require prompt Claims Examiner (CE) attention or action. The FN is able to assist the CE by identifying the issues as they arise and recommending appropriate interventions.

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2. Treating Physician/Medical Provider(s). The FN should work with the injured worker (IW) and treating physician/medical provider(s) to coordinate and facilitate approved medical care with the goal in mind to obtain maximum medical recovery and a release to return to work (RTW). The FN's participation at key medical appointments and maintaining close communications with the treating physician/medical provider(s) involved with the IW's care allows the FN to facilitate medical treatment and identify any obstacles/barriers to the medical management process in a timely manner.

a. Assisting the Treating Physician/Medical Provider(s). The FN can assist the treating physician/medical provider(s) by authorizing certain non-invasive procedures and testing related to the accepted work-related injury. See Part 8 of this handbook for the specific authorizations that can be approved by a FN.

For medical services (including invasive procedures) and/or testing that must be approved by the CE, the FN can assist the treating physician/medical provider(s) by ensuring that the authorization requests are appropriately submitted, and by bringing such submitted requests to the attention of the CE for prompt review and action.

b. Identifying Obstacles/Barriers. While monitoring the ongoing progress of the IW's medical recovery, the FN may identify obstacles/barriers. It is imperative that these obstacles/barriers are brought to the CE's attention as soon as possible. Examples include, but are not limited to:

(1) The treating physician is not participating in the recovery process and/or not providing a treatment plan to facilitate the IW's recovery from the work-related injury;

(2) The treating physician is not participating in the rehabilitation/RTW process and/or not providing a treatment plan with a projected length of disability and goals for a future release to RTW;

(3) The period of disability is extended without clear rationale; and/or

(4) There has been an unexplained (or unapproved) change in the IW's diagnosed work-related injury/condition.

c. FN Recommendations to the CE. To assist in overcoming any identified obstacles/barriers to the successful medical recovery and RTW of the IW, the FN should immediately report such obstacles/barriers to the CE and provide appropriate recommendations for resolution. Such recommendations may include, but are not limited to:

(1) Assisting the CE with identification of case specific issues/questions for resolution by the treating physician in order to obtain clarifying information about the IW's condition, anticipated period of disability, work capacity, treatment plan, etc.;

(2) Recommending a referral to a specialist; and/or

(3) Recommending a referral to a second opinion medical examination (an OWCP directed medical examination which is used when the documentation/reports from the treating physician do not meet the needs of the case; the CE requires clarification of medical issues and statuses; and/or as warranted when requests for surgery approval have been submitted) and assisting the CE with identification of case specific issues/questions for resolution.

d. Follow-up Actions. As a result of any of the above interventions, the FN should be able to continue medical management assistance by taking such interventions as:

(1) Conferring with the CE regarding the anticipated next course of action after obtaining a copy of the second opinion report;

(2) Participating in a team conference with the CE and Staff Nurse (SN) to discuss the current case status and best course of action; and/or

(3) Providing a copy of the second opinion report to the treating physician for review/comment.

e. Assistance When Surgery has been Approved. If surgery has been authorized, the FN may assist in the pre- and post-operative management of medical care for the IW. Such interventions include, but are not limited to:

(1) Attending the pre-operative medical appointment;

(2) Assisting the treating physician with medical service authorization requests and billing submissions;

(3) Helping the IW with recovery coordination and support;

(4) Securing any prescribed and authorized durable medical equipment; and/or

(5) Coordinating prescribed and authorized home health aides.

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