INJURY CLAIM PROCESS - 17th Annual Federal Workers

Report
The Importance of Supervisors’
Roles and Responsibilities
Bryan J Richardson
VHA National Workers’ Compensation Program
Manager
&
Kristin Coyle
VISN 1 Lead WC Specialist
510,423
323,728
$510,423 per day
VHA workers’ compensation chargeback in CBY 2013
$323,728 per day
Portion of VHA chargeback that relates to disability wage loss
LOST PRODUCTIVITY!
Objectives
At the end of this session, you will better understand:
 Impact your role has on injured employees, mission, and cost to
your organization
 How you as a supervisor can prevent employee injuries
 Importance of thorough investigations of all incidents
 How to communicate with workers’ compensation staff
 Your role in return-to-work management
 Timekeeping practices for injured employees
 How to protect information related to on-the-job injuries
Impact of Workers’ Compensation
Impact of Workers’ Compensation
Employee
Self Actualization
Personal Growth & Fulfillment
Esteem Needs
Self Esteem, Self Respect, & Self Confidence
Belongingness & Love
Friendship, Intimacy, & Family
Safety Needs
Personal, Financial, Health, & Well Being
Biological and Physiological Needs
Basic Necessity– Air, Food, Drink, Shelter, Warmth & Sleep
Maslow’s Hierarchy of Needs
Impact of Workers’ Compensation
Agency Mission
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Staff reductions when employee is disabled from work
Over-hiring when employee is out for 365 days
Additional HR activity to ensure entitlements to
injured workers
Overtime requirements for healthy employees
LOSS OF PATIENT CARE RESOURCES
INABILITY TO SERVE OUR VETERANS THE BEST WE CAN
Impact of Workers’ Compensation
Agency Budget
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Chargeback Costs
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Continuation of Pay
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Indirect Cost
Impact of Workers’ Compensation
Chargeback Costs
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Employees Compensation Fund (Congressional Appropriation)
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DOL-OWCP pays medical bills and compensation on
accepted claims
DOL-OWCP charges back the cost to the Agency every year,
including an administrative fee
Agency has two fiscal years to pay the bill
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Repayment is returned to the Employees Compensation Fund
Funds future year payments from Employees Compensation Fund
Each Administration pays its share of the cost
Impact of Workers’ Compensation
Continuation of Pay
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FECA provides that the employer must continue the
employee's regular pay during any periods of resulting
disability, up to a maximum of 45 calendar days.
Entitlement to 45 days must start within 45 days from
DOI
Employer paid at 100% of the employees salary which
is subject to taxes and all other payroll deductions that
are made from regular income.
The employer, not OWCP, pays COP.
Impact of Workers’ Compensation
Continuation of Pay (COP)
 Employer has the right to ‘controvert’ COP entitlement
 If a claim is denied by OWCP, COP is rescinded, Employee
must elect AL, SL or LWOP in lieu of COP
 Employees are not automatically entitled to COP
 Eligibility requirements apply
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Must file a CA-1 for a traumatic injury
Claim must be filed within 30 days from the date of injury
Must have lost time within 45 days from injury
Impact of Workers’ Compensation
Indirect Cost
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Overtime – Results in 2.5 times salary for same service
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Replacement receives overtime
Injured employee receives COP or disability compensation
Over-hiring – Recruitment, on-boarding, & Training
Approximately 27% of employee salary
WC Program Importance
WC Program Importance
Did you know that long-term disability recipients…
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Receive up to 75% of their salary – TAX FREE when on
compensation?
Receive Cost of Living Adjustment(COLA), or raises
while Federal wages are frozen?
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Based on CPI - inflationary indicator that measures the
change in the cost of a fixed basket of products and services.
For 2013, the CPI increase was 1.7%
May be exempt from paying mortgages or car loans
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If employee pays for disability insurance on their own.
WC Program Importance
Your roles and responsibilities to the WC Program
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Pre-Injury responsibilities
Investigation of incidents
Communication with workers’ compensation staff
Timely completion and forwarding of claim forms
Proactive participation in return-to-work efforts
Appropriately document injury-related timekeeping
Protecting workers’ compensation data
Pre-Injury Responsibilities
Pre-Injury Responsibilities
Eliminating Hazards in the workplace is your
BEST method of preventing injuries and illnesses
 Enforce VA OSH rules, regulations, and standards within
your area of responsibility.
 Identify unsafe and unhealthy conditions and practices
in the workplace and take prompt corrective action.
 Encourage employee suggestions on how to improve
Occupant Safety and Health.
Pre-Injury Responsibilities
Observation of employee work practices and
constructive guidance is just as important
 Ensure employees under your supervision are:
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Trained to perform their work safely and such training is
properly documented
Aware of the hazards, if any, involved in their normal work
functions, and that such training is properly documented.
 Initiate progressive disciplinary action, as appropriate,
against employees who repeatedly violate safe work
practices and procedures.
Pre-Injury Responsibilities
Near Miss incidents serve as a ‘dress rehearsal’
for injuries and illnesses in the workplace
“There is one Serious Injury for
every 600 near miss incidents”
Frank Bird – US Safety Researcher
Investigation of Incidents
Investigation of Incidents
 Supervisor
• Gather facts related to the incident
• Obtain witness statements if necessary
• Communicate findings to Safety and WCP staff
• Complete VA Form 2162, Incident Report within 3 working days.
 Safety Officer
• Designated point of contact for secondary incident investigation
• Serves as consultant in work-related accident investigations.
 The WCP staff
• Collaborates with employee, supervisor, and Safety
• Determines relevant facts of the case
• Transmits the case to DOL, if appropriate
Investigation of Incidents
 Office of Workers’ Compensation Program (OWCP)
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Exclusive authority to administer, interpret and enforce FECA
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Sole adjudication authority for FECA processes
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When an employee disagrees with a decision made by OWCP,
they may appeal to OWCP
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Liability under FECA is exclusive and instead of all other direct
judicial proceedings, civil actions, or under a Federal tort
liability statute.
Investigation of Incidents
Step 1:
Determine if emergency treatment is required!
Ensure that employees under your supervision receive
prompt and appropriate medical attention in the event of
an injury or illness.
Such medical services are offered—not mandatory.
Investigation of Incidents
Step 2: Gather facts related to the incident
 Determine causal and contributing factors
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Causal Factor - Any behavior, omission, or deficiency that if
corrected, eliminated or avoided probably would have
prevented the incident or injury.
Contributing Factor - Any behavior, omission, or deficiency that
sets the stage for an incident or increases the severity of injuries
or extent of property damages.
 Identify necessary corrective actions
Investigation of Incidents
Investigating for Causal and Contributing Factors
 Who – Was involved or witnessed?
 What – Occurred or was seen?
 Where – Did it occur, and where were witnesses?
 When – Did this occur or when was it reported?
 Why, Why, Why, Why, Why?
 Any other factors relative to the incident?
Investigation of Incidents
Step 3: Document investigation on VA Form 2162
Step 4: Determine OSHA Recordability
Step 5: Collaborate with WC staff on findings
Step 6: Implement corrective actions
Investigation of Incidents
 Implement Corrective Actions
Correcting hazards prevents future injuries and illnesses!
Communication with WC Staff
Communication with WC Staff
 Your facility WC staff has no authority to accept or deny
workers’ compensation claims
 However, they are able to provide objective evidence of
dispute for consideration by the OWCP
 Findings from your incident investigation may either
support or refute an employee’s statement on CA-1 or
CA-2.
Communication with WC Staff
Disputing an employee’s claim
 WC staff submits a letter of dispute to OWCP
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Describe the factual allegation or argument to support
disagreement
Provide evidence or argument to support the agency’s position
Include supporting documents such as witness statements,
medical reports or records, or any other relevant information.
 Timeliness is key! Dispute must be submitted to OWCP:
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CA-1: With the notice of traumatic injury or death
CA-2: Within 30 calendar days from the date notice of
occupational disease or death is received from the claimant.
Communication with WC Staff
Disputing an employees claim (continued)
 If a letter of dispute is not submitted appropriately,
OWCP may accept the claimant's report of injury as
established.
 A disagreement with an aspect of the claimant's report
is not cause to:
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Delay forwarding the claim to OWCP
Compel or induce the claimant to change or withdraw the
claim.
Communication with WC Staff
Discussion Points with WC Staff
 Has employee established burden of proof – 5 Elements?
1.
2.
3.
4.
5.
Timely Filed (3 year statue of limitations)
Employee of the United States
Fact of Injury
Performance of Duty
Causal Relationship
Communication with WC Staff
Fact of Injury may be questioned if:
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Employee statements and investigation findings are
inconsistent
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Evidence of a previous injury to the same part of the body
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There is a delay in reporting the injury
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You have knowledge of other employment or reserve duty
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There are documented past violations of safe work practices
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Notification of misconduct or pending termination was given
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Leave requests during injury period have been denied
Communication with WC Staff
Performance of Duty may be questioned if:
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The injury occurred outside of working hours
The employee was not performing assigned duties
at the time of injury
The injury occurred off premises?
The injury occurred during a recreational activity
Horseplay, willful misconduct were involved
Injury was a result of a vehicular accident
Injury was the result of an assault
Communication with WC Staff
 Employees are considered to be in the
Performance of Duty on premises including steps,
sidewalks and parking lots owned, controlled or
managed agency:
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During work hours and/or on breaks
Outside working hours
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Usually considered 30 minutes before or after working hours
Not extended to employees who are visiting the premises for
non-work-related reasons.
Performing representational functions entitling them to
official time are covered.
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Injuries to employees engaged in the internal business of a
labor organization are not covered.
Communication with WC Staff
Causal Relationship is a medical determination
usually addressed by the OWCP Claims Examiner.
Communicate with the WC staff if you have concerns that the
medical condition identified by the employee is not causally
related to the claimed injury.
The following Statutory Exclusion should also be addressed with
the WC staff
• Willful misconduct
• Alcohol or drug impairment involved
• Intent to injure self or others
Communication with WC Staff
In cases of work-related employee death
 Notify the Facility Workers’ Compensation Office
immediately to report a death due to a work-related
traumatic or occupational disease-facility workers’
compensation office will notify OWCP immediately via
telephone or fax
 Complete form CA-6, Official Superior’s Report of
Employee’s Death, immediately so facility workers’
compensation office can submit to OWCP within 10
workdays from notification
Claim Initiation Process
Claim Initiation Process
Supervisor
WC Staff
Provide Guidance and Counsel to Injured Employees
Communicate Employee Rights and Responsibilities
Provide Notice of Choice of Physician
Provide Release of Information Document
Investigate Incident
Dispute Questionable Claims
Emergency Treatment (if needed)
Authorize use of CA-16
Respond to Development Letters & Requests from OWCP timely
Ensure Leave Requests are Made
Authorize use of COP if applicable
Periodically Check on Employee
Track OWCP Pending Actions
Injury-Related Timekeeping
Supervisor
WC Staff
Ensure Entitlement to COP
Ensure Leave Requests are Made
Track COP Day Count
Ensure Appropriate Leave is Used
Authorize Requests for COP
Forward Medical to WC Staff
Controvert COP when applicable
Notify Employee of Controversion
Notify Employee when Controversion Upheld
Request Election of Other Leave
Rescind COP when Case Denied
Review COP Cost for Facility
Claim Initiation Process
For Traumatic Injuries:
 Advise the injured employee of his or her right to file for
workers’ compensation benefits using Form CA-1.
 Complete the required fields of the VA 2162, the Incident Report
within 5 days.
 Complete the required fields of the supervisory portion of the
Form CA-1 within 3 days of signing by the employee.
 Do not delay injury claim completion while waiting for other
documents or disputes to be completed.
Claim Initiation Process
A claims is not complete until:
 Employee has electronically signed
 Supervisor has electronically signed
 The claim form has been printed and both the employee’s and
supervisor’s wet ink signature has been obtained
 A claim will not be transmitted/submitted to OWCP without wet
ink signature
Claim Initiation Process
Here’s the fine print:
 No employer or other person may require an employee or other claimant to
enter into any agreement, either before or after an injury or death, to waive
his or her right to claim compensation under the FECA. No waiver of
compensation rights shall be valid. 20 CFR 10.15
 A number of statutory provisions make it a crime to file a false or fraudulent
claim or statement with the government in connection with a claim under the
FECA, or to wrongfully impede a FECA claim. See 20 CFR 10.16, Title 18 U.S.
C. section 287, 1001. 1920, and 1922.
 Administrative proceedings may be initiated under the Program Fraud Civil
Remedies Act of 1986 (PFCRA), 31 U.S.C. 3801-12, to impose civil penalties
and assessments against persons who make, submit, or present, or cause to
be made, submitted or presented, false, fictitious or fraudulent claims or
written statements to OWCP in connection with a claim under FECA. 29 CFR
Part 22
Claim Initiation Process
18 U.S.C. 1922 - False or withheld report concerning FECA
Whoever, being an officer or employee of the United States charged with
the responsibility for making the reports of the immediate superior
specified by section 8120 of title 5, willfully fails, neglects, or refuses to
make any of the reports, or knowingly files a false report, or induces,
compels, or directs an injured employee to forego filing of any claim for
compensation or other benefits provided under subchapter I of chapter
81 of title 5 or any extension or application thereof, or willfully retains
any notice, report claim, or paper which is required to be filed under
that subchapter or any extension or application thereof, or regulations
prescribed thereunder, shall be fined under this title or imprisoned not
more than one year, or both.
Return to Work Management
Return to Work Management
Supervisor
WC Staff
Identify Transitional Job Duties
Provide Written Job Offer
Monitor Transitional Duty to Ensure Restrictions are not Exceeded
Notify WC of Updated Restrictions
Update Written Job Offer
Provide Release of Information Document
Monitor any Leave upon RTW
Monitor Medical for RTW Changes
Notify WC Staff-IOD Leave Used
Request Medical to Support Leave
Return to Work Management
 Transitional duty must be made available to injured employees
 The transitional assignment must be provided in writing to the
injured employee with the option of accepting or declining the
offer. (initial in verbal is okay- f/u with written.)
 Transitional duties should align with medical restrictions.
Transitional job offer should not exceed 90-120 days without
modification—This depends on severity of the injury.
Return to Work Management
When medical restrictions are received from the physician, you
will be asked by the WC staff for the following information:
1. Description of duties to be performed
5. Date that the job is available
2. Physical requirements for those duties
6. Work schedule for the job
3. Location where job will be performed
7. Date response to job offer is due
4. Salary information for transitional job
8. If moving expenses will be paid
Return to Work Management
Notify your Facility Workers’ Compensation Office
immediately if you believe an injured employee is off
work as a result of a work injury, don’t take it for granted
they are
Return to Work Management
If a claim is denied by OWCP
 Notify employee of their right to request reasonable
accommodation within 30 days of denial of claim
 Engage the Reasonable Accommodation specialist at
your facility for assistance
Return to Work Management
Supervisors SHOULD NOT:
 Send an employee home because transitional duties
are not available
 Allow an injured employee to perform transitional duty
without a written job offer
 Treat injured employees differently than you treat
other employees. An injury is not a “get out of jail free”
card.
Return to Work Management
Supervisors SHOULD NOT: (continued)
 Allow an employee to dictate what duties he or she
feels he/she can or cannot do
 Withhold taking appropriate administrative or
disciplinary actions against an injured employee
 Impede employee’s election to take annual, sick leave
or leave without pay for time lost because of a jobrelated injury
Return to Work Management
Retention Rights – Separation from Agency Rolls
 Under 5 U.S.C. 8151, an employee who recovers within 1 year of
starting compensation has mandatory rights to his or her old
position or its equivalent, regardless of whether he or she is still
on the Agency rolls
 If full recovery occurs after 1 year, or the employee is considered
partially recovered, he or she is entitled to priority consideration
as long as application is made within 30 days of the date
compensation ceases
 Employees incur no loss of benefits which they would have
received but for the injury or disease.
5 CFR Section 353, 301, 302, and 303
Protecting Employee Data
Protecting Employee Data
VA Systems of Record
 Created or amended as needed to meet the legislative
requirements of the Privacy Act of 1974
 SORNs (System of Record Notices) are in place to protect
employee data.
 VA Systems of Record DO NOT cover employee workers’
compensation records
DOL/GOVT-1 System of Records
 Protects records relating to claims for benefits filed under the
FECA, including any copies maintained by an employing agency
 This system of records is maintained by and under the control of
OWCP, and, as such, all records covered by DOL/GOVT-1 are
official records of OWCP.
Protecting Employee Data
Confidentiality of WC Records
 All records relating to claims for benefits, including copies
of such records maintained by an employer, are considered
confidential and may not be released, inspected, copied or
otherwise disclosed except as provided below:
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Freedom of Information Act
Privacy Act of 1974
DOL/GOVT-1 if such release is consistent with the purpose for which
the record was created.
Protecting Employee Data
Storage and Use of WC Documents
 Workers’ Compensation related documents must be stored in
locked cabinets inside of a locked room
 The use of the information collected must be connected in some
way with the compensation claim
 Agencies may not use copies of information from claim files for
these purposes without written consent of the injured
employee:
a) In connection with EEO complaints
b) Disciplinary actions
c) Other administrative actions
Protecting Employee Data
Employee Right to Representation
 May appoint one individual to represent his or her interest
in the claim process
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Appointment must be in writing
There can be only one representative at any one time
 May authorize any individual to represent him or her in
regard to a claim under the FECA
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A Federal employee may act as a representative only:
• On behalf of immediate family members provided no fee is charged
• While acting as an officially sanctioned union official provided no fee or
gratuity is charged.
ANY QUESTIONS????

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