Attachment 1-Summary Document of Form Revisions

SUMMARY DOCUMENT OF FORM REVISIONS

OMB 1240-0046

OCTOBER 2017

FOR REVISION TO THE CA-1332: In Sections II and III of the letter, added additional questions for the second opinion to address if tinnitus has been diagnosed, whether such diagnosis has impacted daily living activities and whether such diagnosis is due or not due to federal employment. The current letter is insufficient for the physician to comment on these issues.

FOR REVISION TO THE CA-16): DFEC is focusing more on Program integrity issues, in particular medical billing.  This form is intimately tied to those efforts and DFEC would like to incorporate recent and upcoming policy changes (e.g., new guidance/forms for compound and opioid medications OMB 1240-0055).

1. Revised the opening statement at the top of the form:

The following request for information is required under 5 U. S. C. 8101 et. seq. Benefits and/or medical services expenses may not be paid or may be subject to suspension under this program unless this report is completed and filed as requested. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974 and OMB Cir. No. 130. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Note: this form is not to be reproduced or duplicated (See Instructions). If instructions are separated from this form, refer to form instruction https://www.dol/owcpdfec/

2. Under Part A, Authorization:

Revised #1. Name and Address of the medical Facility or Physician Authorized to Provide the Medical Service within the meaning of FECA (See Instructions for definition of qualified physician).

Revised #6. Your signature in item 35 of Part B certifies your agreement that all fees for services shall not exceed the maximum allowable fee established by OWCP and that payment by OWCP will be accepted as payment in full for said services. PLEASE NOTE THIS AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR COMPOUND MEDICATIONS. SEE INSTRUCTIONS FOR ADDITIONAL MEDICAL INFORMATION.

Revised #8. Now #11. Signature of Authorizing Official/Date (Month/Day/Year)

Revised #9. Now #10. Name and Title of Authorized Official (type or Print Clearly) (See Instructions)

Revised #10. Now #9.

Revised #13. Now #8.

Revised #13. Added the following certification statement underneath the authorizing official signature in item 11.

I certify that I am the individual signing this form in item 11 and that I am authorized by my employing agency to issue this form concerning medical treatment. I further certify that the information provided above is true and accurate to the best of my knowledge and belief. I realize that any person who knowingly makes any false statement or misrepresentation to obtain FECA compensation is subject to civil or administrative remedies as well as criminal prosecution.

#14 (New). Added area for remarks per the revised instructions.

Moved Public Burden Statement on same page as the Privacy Act Statement.

3. Under Part B, Attending Physician’s Report:

Revised #35. SIGNATURE OF QUALIFIED PHYSICIAN (see Instructions for definition) I certify that all the statements in this form are true and accurate to the best of my knowledge and belief.  Further, I understand that any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA including payment for medical treatment or supplies or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both, and that physicians are subject to criminal and civil prosecution. In addition, a state or federal criminal conviction for FECA fraud will result in a beneficiary’s termination of all current and future FECA benefits.

Revised Bottom page. PAYMENT/MEDICAL BILLING: This CA-16 guarantees payment to the original treating physician (or any physician to whom the employee was referred by the original treating physician) for 60 days from date of issuance unless OWCP terminates this authority at an earlier date. Treatment may continue at OWCP expense if the claim is approved. Charges for your services should be presented on the AMA standard "Health Insurance Claim Form'' (HCFA-1500, OWCP-1500, OWCP-04 or the UB-04). Physician services must be itemized by Current Procedural Terminology Code (COPT) using current CPT-4 coding schema; or, the UB-04 and the coding schemas acceptable on this form.

4. Revised the top of page for Part A Instructions for Completion of Part A

INSTRUCTIONS FOR AUTHORIZING OFFICIAL FOR COMPLETION OF PART A. Revised: PLEASE READ FIRST. The CA-16 is solely used by the employing agency to authorize emergency care to an injured employee. To protect against potential fraud and abuse, it is important that this form not be duplicated or reproduced without express written consent by OWCP to include via electronic means (including Internet postings). PLEASE ENSURE THESE INSTRUCTIONS ACCOMPANY THE CA-16 FORM.

Added new bullet. AUTHORIZING OFFICIAL Authorized personnel may include an Injury Compensation Specialist, Safety Specialist, or Human Resources Specialist whose current position includes duties relate to the FECA program. The injured employee’s Supervisor or other individual in their supervisory chain of command at the time of injury may also sign and issue this form. If you are other than these noted, please explain in the Remarks section, item 14 of the CA-16 the circumstances which required issuance by you and to what authority, if applicable. Please be aware that union officials, claimant representatives, or others may not serve as an authorizing official unless they meet the criteria listed above.

Revised Selection of Physician.

• If an employee elects to be treated by a private physician; a copy of the American Medical Association Standard Billing Form (AMA) OWCP-1500 should be supplied together with the submitted Form CA-16. Additionally, medical providers should register with the OWCP Medical Bill Processing Contractor in order to receive payment. Further information can be found on the DFEC website at https: www.dol.gov/owcp/dfec/

Revised Definition of Physician. Qualified Medical Facility/Physician.

Qualified hospital means any hospital licensed as such under State law which has not been excluded by the FECA program in accordance with its governing regulations. Except as otherwise provided by regulation, a qualified hospital shall be deemed to be designated or approved by OWCP.

Qualified provider of medical support services or supplies means any person, other than a physician or a hospital, who provides services, drugs, supplies and appliances for which OWCP makes payment who possesses any applicable licenses required under State law, and who has not been excluded.

The term “physician” includes doctors of medicine (MDs), surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practioners within the scope of their practice as defined by State law. The reimbursable services of chiropractors under the FECA are limited by statute to physical examination related laboratory test and X-rays to diagnose a subluxation of the spine and treatment consistent of manual manipulation of the spine to correct a subluxation demonstrated by X-ray.

Qualified physician means any physician who has not been excluded under the provisions of subpart I of this part. Except as otherwise provided by regulation, a qualified physician shall be deemed to be designated or approved by OWCP. (See 20 CFR. 10.5, WHAT DEFINITIONS APPLY TO REGULATIONS IN THIS SUBCHAPTER)

5. Instructions for Completion of Part B:

Revised Under Your Authorization, 3^rd bullet. This form does not cover elective and non-emergency surgery, home exercise equipment, whirlpools, mattresses, spa/gym membership and work hardening programs. ALSO, PLEASE NOTE THIS AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR COMPOUND MEDICATION.

Under Billing for Services, revised with two new bullets

All medical providers must be enrolled with our Medical Bill Processing Contractor in order to receive authorization and payment. Additional information can be found on our website at www/dol.gov/owcp/dfec.

If an employee elects to be treated by a private physician; a copy of the American Medical Association Standard Billing Form (AMA) OWCP-1500 should be supplied together with the submitted Form CA-16.

FOR REVISION TO THE CA-1331

Fourth paragraph, revised the sentence to read

If a patient obstructs the examination or fails to give you full cooperation in obtaining legitimate thresholds, or if you have reservations as to the audiometric studies, find them inadequate, or perceive indications of potential malingering, please report and document that concern/reservation and arrange for retesting and/or additional testing as required. Any special studies required to attempt to resolve such questions, such as ABERS, are approved for payment.

FOR REVISION OF THE CA-1090

In second paragraph, clarified paragraph to distinguish requirements between those seeking benefits before or after January 4, 1999.

3^rd paragraph revised to note that payments were subject to a medical fee schedule and maybe reviewed by OWCP staff to ensure services are rendered by appropriately trained individuals.

Revised Question 4 of the Claimant Questionnaire to be completed only by those in receipt of attendant services prior to January 4, 1999.

Revised Certification Statement and deleted reference to felony conviction, instead, rewrote in part, subject to criminal prosecution or civil fraud action.

For the Treating Physician Questionnaire

Question 5, changed the name “institution” to “residential facility”

Question 7, added two more entries regarding bathroom/incontinence products.

Question 9. Revised to include the physician’s specialty.

OTHER MINOR REVISIONS WHICH APPLY TO ALL OF THE FORMS/LETTERS.

REVISED THE ACCOMMODATION STATEMENT FOUND ON EITHER THE BOTTOM OF THE PAGE/INSTRUCTIONS OF THE FORMS/LETTERS.

Bottom of page.

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP. See form instructions for REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.

Instructions

NOTICE REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES IF YOU HAVE A DISABILITY, FEDERAL LAW GIVES YOU THE RIGHT TO RECEIVE HELP FROM THE OWCP IN THE FORM OF COMMUNICATION ASSISTANCE, ACCOMMODATION(S) AND/OR MODIFICATION(S) TO AID YOU IN THE CLAIMS PROCESS. FOR EXAMPLE, WE WILL PROVIDE YOU WITH COPIES OF DOCUMENTS IN ALTERNATE FORMATS, COMMUNICATION SERVICES SUCH AS SIGN LANGUAGE INTERPRETATION, OR OTHER KINDS OF ADJUSTMENTS OR CHANGES TO ACCOMMODATE YOUR DISABILITY. PLEASE CONTACT OUR OFFICE OR YOUR OWCP CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE