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Federal Workers' Compensation

The Office of Workers' Compensation Programs administers four major disability compensation programs which provide wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to certain workers or their dependents who experience work-related injury or occupational disease.

Here is a forum for members to share and exchange experiences regarding to workers' compensation related issues.

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#1 Posted : Tuesday, February 5, 2019 8:59:32 AM(UTC)

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I have an accepted claim for R knee injury sustained in 2011. I was given surgical auth for Partial Knee replacement and had surgery in 2011.
I returned to work in 2012...filed for, and was given a Scheduled Award a year or so later.

In 2014 I had an accepted injury to my L knee and another claim # was issued...had partial L knee replacement same year. After 3 OWCP IME exams, I was determined to be permanently disabled. I never returned to work. In 2018, L knee failed and was given auth for L TKR.

Because I was favoring my L knee...In October 2018, my R knee failed and Dr requested auth for R TKR. Received letter from OWCP DME requesting addt'l. info and my surgeon submitted xrays, notes, etc. And have not heard back since.
I spoke to my claims rep, who is new to claim and he had a hard time distinguishing between the L knee claim # and the R knee claim #. He said he would look into it.
Prior to my R knee failing, Dr was treating my R knee with several cortisone shots and billed under R knee claim number. All were paid.

Now, when I log into OWCP CONNECT, my R knee Claim appears, but when I look under authorizations there is no record of ANY authorizations including the one in 2011. No surgical auth, no PT auth, no OWCP nurse auth, no treatment auth...NOTHING for any date range I enter! It's as if any auth for R knee never existed!

Question: How do I proceed? Who can I speak to? My R knee has gotten so bad I cannot bear weight on it now.
Does receiving a Scheduled Award close a Case File Number? (They did pay for cortisone injections under that same number after SA).

At wits end!!!

#2 Posted : Thursday, February 7, 2019 11:12:44 AM(UTC)

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I think that it is very likely that older authorizations disappear from the system after awhile. They are there to insure that medical bills related to the surgery, PT, etc., get paid. Since all bills have to be submitted d by the end of the year, following the year in which the service was rendered, older auths probably drop off after three or four years. It reduces "clutter" and makes current easier to find.

If you had an authorized surgery in 2011, the bills for same probably were processed NLT 12/31/2012. It is now 2019!

The records related to your surgery should be in the relevant OWCP case file as well as an imaged copy of the authorization letter that was sent out back in 2011. OWCP Connect is primarily for the benefit of you and the relevant members of the medical community. But it is "contemporaneous". The claims examiners really do not use it in their decision making. They would look at your OWCP file instead and find the surgical reports, previous autho letter, etc.

The scheduled award did not close out your claim for medical treatment. If your physician now wants to be do a TKR, have him submit an autho request under the relevant case number for same. He can cite the previously authorized surgery, etc. as part of his justification for the autho request.
#3 Posted : Thursday, February 7, 2019 4:01:55 PM(UTC)

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Thanks edalder....
My Dr did submit medical info, treatments, and imaging along with request for TKR auth.

First DMA needed more info, which Dr submitted. Now claims examiner says DMA says there’s insufficient info, again, and wants to send me to their IME!

What can their IME determine on his own? He will have the same evidence my Dr sent to DMA! Doubt he’ll take his own xrays or MRIs.
In speaking with claims examiner today, I asked if he sent DMA the xrays...then he said he would re submit all info to DMA.
WHAT GIVES? Is claims examiner not doing job properly?
Can I appeal to claims supv?
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