Division of Federal Employees' Compensation (DFEC)
Paragraph and Subject
FNHB Trans. No.
Table of Contents
1. Authority. Services of OWCP Certified Nurses are provided under the auspices of 5 U.S.C. §8103(a), which states:
The United States shall furnish to an employee who is injured while in the performance of duty, the services, appliances, and supplies prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of the monthly compensation.
20 C.F.R. §10.310(a) specifically provides 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. See Part 10 of this handbook for further information on disclosure of information authority for contract nurses.
In addition, when an injured worker (IW) signs the Form CA-1, Notice of Traumatic Injury, or Form CA-2, Notice of Occupational Disease, when filing a claim for workers' compensation benefits, s/he has given consent for authorization of the release of information. The Forms specifically state "I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative). This authorization also permits any official representative of the Office to examine and to copy any records concerning me." As such, no additional Release of Medical Information form is necessary.
2. Objectives of the Nurse Intervention Program (NIP). The OWCP is committed to seeing that benefits for compensation and medical services are appropriately and timely provided. The OWCP is also committed to assisting IWs in obtaining a successful medical recovery and minimizing the period of disability from work.
As part of the early disability management process and to further these goals, OWCP created the NIP. The objectives of the OWCP NIP include, but are not limited to:
a. Facilitating and coordinating medical care in a timely manner;
b. Facilitating the identification of work tolerance limitations;
c. Assisting the IW and key employing agency (EA) personnel in the return to work (RTW) process, thereby reducing the length of the disability associated with work injuries/illnesses; and
d. Promptly identifying and recommending referrals for those cases that may benefit from participation in the OWCP Vocational Rehabilitation Program.
3. Participants in the Nurse Intervention Program (NIP). The Disability Management process is a collaborative effort. While the OWCP Claims Examiner (CE) maintains authority over the case management actions, communication between all participants in the NIP is essential to reaching the goals and objectives established for any disability case (medical recovery and re-employment of IWs).
a. National Office Nurse Consultant (NONC). The NONC serves as the National Coordinator for the OWCP NIP.
b. OWCP District Office Staff Nurse (SN). Each District Office retains the services of a SN to administer the policies and procedures of the OWCP NIP. The SN directs contract nurse services in accordance with OWCP/DFEC policies and procedures related to the NIP to ensure quality, effective and timely services. The SN facilitates the interactions and communications between the NIP participants, and also identifies medical issues or obstacles that need prompt attention. The duties of the SN include, but are not limited to:
(1) Managing assignments of contracted nurses to OWCP cases;
(2) Monitoring contract nurses' performance in correlation to both the contract specifications and the quality of services provided, and intervening promptly to address work product issues when deficiencies occur;
(3) Consulting with the CE and nurse regarding treatment plans and medical services so that established case management goals are being accomplished;
(4) Reviewing, evaluating, and processing nurse reports to ensure completeness and timeliness prior to authorizing payment of bills;
(5) Developing working relationships with, and serving as a liaison and resource for, EAs and their representatives in order to establish positive and productive communications; and
(6) Serving as the District Office subject matter expert regarding nurse intervention policy and services.
c. Responsible Claims Examiner (CE). The CE maintains authority over all case management actions. The CE is responsible for the following types of actions/decisions:
(1) Determining benefit eligibility, developing, approving and/or denying compensation payments and benefit rate adjustments;
(2) Developing, authorizing, and/or denying medical services, treatment plans, hospitalizations, etc.;
(3) Identifying cases that would benefit from nurse services and completing the referrals to the SN as quickly as possible;
(4) Consulting and communicating with assigned contract nurses concerning case management activities and progress;
(5) Reviewing nurse reports and medical treatment plans to ensure that they are in keeping with the established goals and objectives so that the case management activities proceed according to the FECA guidelines;
(6) Evaluating and determining suitability of job offers; and
(7) Identifying cases that would benefit from OWCP's Vocational Rehabilitation Program.
d. OWCP Certified Continuation of Pay (COP) Nurse. COP Nurses (CN) are contracted nurses assigned to traumatic injury cases where the IW has immediate time loss and has not returned to work within seven (7) days following the date of work stoppage. The CN enables the District Offices to identify cases in need of prompt adjudication and assists the CEs in prioritizing their adjudication efforts. The CN is strictly a triage nurse and all work is performed telephonically.
Within seven (7) days of case assignment, the CN is expected to contact the IW, the EA and the treating physician. At a minimum, the CN should obtain a history of the injury from the IW; 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 provided to the CE (via the COP Nurse Closure Report) 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 assignment.
e. OWCP Certified Field Nurse (FN). The FN is a contracted Registered Nurse who assists in the management of disability claims by utilizing and providing specialized nurse case management skills, techniques and knowledge in the context of the workers' compensation arena. The FN provides a comprehensive nursing assessment of the IW's abilities, needs and concerns as they relate to the response to, and recovery from, a work injury; and in doing so, the FN then develops and implements a nursing case management plan to address those abilities, needs and concerns. As part of this ongoing process, the FN evaluates the outcome of his/her interventions and makes necessary adjustments to the individual nurse case management plan as the IW's status changes throughout the FN phase of disability management.
(1) The FN is responsible for coordinating appropriate medical care, expediting the delivery of care, and serving as a liaison between the IW, medical provider(s), EA and CE. As an active member in a team approach, the FN assists the IW in facilitating maximum medical recovery with a safe and timely RTW. FN interventions and activities assist the CE in moving a disability case towards resolution.
(2) The FN's contact with the IW is generally in person, however, in some instances the contact may be only telephonic in nature.
(3) A FN is expected to adhere to the DFEC and OWCP policies and procedures and follow the instructions of the CE and SN.
(4) The FN is expected to develop a nurse case management plan which identifies any medical issues and/or concerns related to the IW's recovery and RTW potential, determine the goals of the recommended treatment plan, monitor the results of the ongoing treatment plan to ensure progress toward the desired outcome(s), and recommend additional resources, as necessary, to assist in overcoming any obstacles that may arise during the treatment and RTW process.
The FN may perform some or all of the following activities:
(a) Provide an assessment of the IW's current status, whichincludes but is not limited to: the extent of injury, functional ability, response to medical treatment(s) to date , current work status and an estimated RTW date;
(b) Meet with the IW's treating physician to discuss the IW's current medical status and active treatment plan to ensure appropriate measures are in place to facilitate recovery and RTW;
(c) Coordinate recommended and approved medical care (referrals to specialists or other health care providers, diagnostic testing, surgery, home care services, etc.);
(d) Collaborate with the EA to identify light duty work accommodations and/or barriers to the RTW efforts, and coordinate the RTW in a timely manner;
(e) Coordinate the transition of the IW's RTW via participation in on-site visits and follow-up monitoring;
(f) Identify any physical limitations or other barriers impacting the IW's adaptability to work duties; and/or
(g) Make recommendations for possible vocational rehabilitation referrals.
The FN must:
(a) Submit thorough and accurate case reports and bills according to OWCP policies and procedures; and
(b) Communicate promptly to the CE all case milestones/activities that require his/her attention (i.e. work stoppage, recurrence of symptoms, unrelated medical issues).
See Parts 3, 4 and 5 of this handbook for further information regarding the activities and interventions expected of an OWCP Certified FN.
f. The Injured Worker (IW). The most important participant in the disability management process is the IW as it is his/her active involvement and cooperation that facilitates medical recovery and RTW following a work injury. The CE, EA and FN need to convey to the IW the concept of the FECA as encompassing a RTW program, and assist the IW in understanding that nurse case management interventions focus on actions that promote the achievement of medical recovery and RTW.
The IW should:
(1) Cooperate with the OWCP NIP; and
(2) Actively participate in his/her own medical rehabilitation and recovery.
The IW must:
(1) Accept appropriate light duty assignments and seek and accept appropriate and suitable work once total disability has ceased; and
(2) Cooperate with vocational rehabilitation.
g. The Employing Agency (EA). The EA has a vested interest in returning the IW to work as soon as possible. As a result, partnering with the EA throughout the RTW process is important to achieving a successful outcome. The EA's responsibilities include:
(1) Submitting completed program required documents and forms in a timely manner;
(2) Effectively communicating the purpose of the FECA to the IW and conveying from the onset that medical recovery and RTW are the ultimate goals;
(3) Maintaining contact with the IW and addressing the IW's concerns about personnel issues such as retirement or health insurance benefits that may be affected by a RTW;
(4) Re-employing IWs who have recovered either fully or partially from an employment-related injury or illness, and who can perform the duties of the original job or its equivalent within one year from the on-the-job injury (see 5 U.S.C. 8151);
(5) Offering light or modified duty to IWs who cannot resume the full duties of their date of injury job; and
(6) Cooperating with the NIP, to include collaborating with the FN to identify appropriate and suitable work and allowing access to the IW's work site.
h. Medical Providers. Establishing a good relationship with medical and health care service providers is essential in obtaining a successful disability management outcome. The goal of medical intervention in disability cases is to address and resolve medical issues in order to assist the IW with recovery and RTW. To facilitate recovery and RTW, ideally medical providers and ancillary health care service providers should:
(1) Cooperate with the OWCP FN;
(2) Communicate treatment plans and any changes in the IW's medical status to the FN; and
(3) Collaborate with the FN and IW on issues related to RTW plans and projections.