Office of Workers' Compensation Programs: Further Actions Are
Needed to Improve Claims Review (09-MAY-02, GAO-02-637).
The Department of Labor's Office of Workers' Compensation
Programs (OWCP) paid $2.1 billion in medical and death benefits
and received about 174,000 new injury claims during fiscal year
2000. GAO found that (1) one in four appealed claims' decisions
are reversed or remanded to OWCP district offices for additional
consideration and a new decision because of questions about or
problems with the initial claims decision; (2) OWCP set a goal of
informing 96 percent of claimants within 110 days of the date of
the hearing; (3) nearly all doctors used by OWCP to provide
opinions on injuries claimed were board certified and state
licensed, and were specialists in areas consistent with the
injuries they evaluate; and (4) OWCP has used mailed surveys,
telephone surveys, and focus groups to measure customer
satisfaction. The Labor inspector general is monitoring fraud
within OWCP's workers compensation program and using the claims
examiners as one source in identifying potentially fraudulent
claims.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-02-637
ACCNO: A03286
TITLE: Office of Workers' Compensation Programs: Further Actions
Are Needed to Improve Claims Review
DATE: 05/09/2002
SUBJECT: Claims processing
Claims reconsiderations
Claims settlement
Compensation claims
Customer service
Internal controls
Physicians
Workers compensation
DOL Black Lung Program
SSA Disability Program
******************************************************************
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GAO-02-637
A
Report to the Chairman, Subcommittee on Government Efficiency, Financial
Management and Intergovernmental Relations, House of Representatives
May 2002 OFFICE OF WORKERS? COMPENSATION PROGRAMS
Further Actions Are Needed to Improve Claims Review
GAO- 02- 637
Letter 1 Results in Brief 2 Background 3 Scope and Methodology 6 Evaluation
Problems, Case File Mismanagement, and New Evidence Are Reasons Appealed
Claims Decisions Are Reversed or
Remanded 7 OWCP Has Established a Hearing Standard That Allows 110 Days for
Claimant Notification 12 OWCP?s Physicians Were Board Certified, Licensed,
and Had
Specialties Consistent with the Injuries Examined 14 OWCP Uses Several
Methods to Identify Customer Concerns and Assists DOL?s IG in Addressing
Potential Claimant Fraud 16
Conclusions 19 Recommendation for Executive Action 20 Agency Comments and
Our Evaluation 20
Appendixes
Appendix I: OWCP?s Claims Process 26
Appendix II: Scope and Methodology 30
Appendix III: Sampling and Estimation Methods and Sampling Errors 33
Appendix IV: Comments from the Department of Labor 35 Tables Table 1:
Sampling Error of Estimates for Appealed Claims
Decisions to ECAB and BHR between May 1, 2000, and April 30, 2001 34
Figures Figure 1: Percentage of Appealed Claims Decisions Affirmed,
Remanded, and Reversed by BHR or ECAB during Period
from May 1, 2000, through April 30, 2001 8 Figure 2: Claims Process 28
Abbreviations
ABMS American Board of Medical Specialties BHR Branch of Hearings and Review
DOL Department of Labor ECAB Employees' Compensation Appeals Board FECA
Federal Employees Compensation Act IG Inspector General OWCP Office of
Workers? Compensation Programs PHS Public Health Service
Letter
May 9, 2002 The Honorable Stephen Horn Chairman, Subcommittee on Government
Efficiency,
Financial Management and Intergovernmental Relations Committee on Government
Reform House of Representatives
Dear Mr. Chairman: During fiscal year 2000, the Department of Labor?s (DOL)
Office of Workers? Compensation Programs (OWCP) paid about $2.1 billion in
workers? compensation benefits to federal employees, including wage loss,
death, and medical benefits stemming from job- related injuries and OWCP
received approximately 174, 000 new injury claims. When a federal employee
incurs expenses or misses significant time from work due to onthe- job
injury or illness, the employee may submit a claim to OWCP for workers?
compensation. If all or a portion of the claim is denied by OWCP, the
claimant may appeal the decision. During the last few years, a number of
issues related to OWCP?s adjudication process for appealed claims decisions
have been raised in related congressional hearings, including instances
where federal employees felt their claims had been improperly denied. As a
result, you requested that we examine and provide you with information on
selective aspects of the OWCP adjudication process, specifically:
the frequency and primary reasons why appealed claims decisions are
reversed or remanded to OWCP district offices for additional consideration;
1
the extent to which OWCP is complying with the Federal Employees
Compensation Act?s (FECA) requirement to inform claimants within 30 days
about the outcomes of appeal hearings;
1 A reversal means the current decision on the claim was determined to be
incorrect and the decision was changed, while a remand means the claim was
sent back to the district office or BHR for additional work and a new
decision and does not necessarily indicate that the current decision was
incorrect.
the extent to which OWCP is using certified and licensed physicians to
provide opinions on injuries claimed and whether the physicians? areas of
specialty appear to be consistent with the injuries they evaluate; and
methods OWCP uses to identify customer satisfaction and potential claimant
fraud.
Results in Brief We estimate that approximately 25 percent of 8, 100
appealed claims, for which decisions were rendered during the period May 1,
2000, through
April 30, 2001, were either reversed or sent back (remanded) to OWCP
district offices for further development due to questions about or problems
identified with the initial decisions. OWCP claims decisions summaries
indicated these problems predominantly involved either (1) improper
evaluations of medical or nonmedical evidence or (2) mismanagement of claim
files. When claims are initially denied and then later approved upon appeal,
claimants must manage without benefits during the appeals process, which can
involve significant periods of time and additional expenses to the claimant,
such as representatives? fees, that are not
reimbursable. OWCP monitors reversed or remanded claims decisions to
identify trends and problems with district office decisions and provides
information to claims examiners on reversals and remands. However, OWCP does
not have information on the frequency of specific reasons for
these reversals and remands. Such information might better enable OWCP and
its district offices to understand factors contributing to these reversals
and remands and to address their underlying causes, possibly reducing
current levels of reversals and remands. We are recommending that the
secretary of labor require the director of OWCP to examine steps now being
taken to determine whether more can be done to identify and track
specific reasons for remands and reversals- including improper evaluation of
evidence and mismanagement of claim files- and address their underlying
causes.
FECA requires OWCP to inform claimants of their decision on appeals within
30 days after the related hearing. OWCP has interpreted this requirement in
a manner which allows certain administrative steps to occur over a longer
period of time. They have factored in time to allow both the claimants and
employing agencies to comment on hearing transcripts and conduct other
activities it believes are important to complete following the hearing date
before rendering its final decisions on appeals. Considering these factors,
OWCP has established a goal of notifying nearly all claimants
of final claims decisions within 110 days of the hearing date. We estimate
that 92 percent of claimants are notified within this timeframe. While FECA
does not require contracted physicians used by OWCP to be board certified or
state licensed, our review found that OWCP is generally adhering to its own
requirements that physicians it uses to settle disagreements between a
claimant?s and OWCP?s second opinion physicians are (1) certified by medical
boards in their areas of medical specialty, and (2) licensed by state
authorities. In addition, we estimate that 98 percent of the time, OWCP-
contracted physicians were specialists in medical areas that were
appropriate for the types of claimant injuries they examined.
OWCP has used surveys and focus groups to monitor customer satisfaction.
Regarding the overall program, a survey taken in 2000 resulted in a 52
percent satisfaction rate and a 47 percent dissatisfaction rate. The level
of claimant satisfaction indicated in their survey responses for specific
issues or aspects of the program has been largely mixed (i. e., more
positive responses for some questions and more negative responses for other
questions).
To prevent and deter fraudulent activity, DOL?s Office of the Inspector
General (IG) follows up on concerns raised by examiners and other sources
and, where appropriate, conducts investigations of claimants and medical
providers suspected of defrauding the program. For fiscal years 1998 through
2001, approximately 500 investigations were opened, resulting in 212
indictments and 183 convictions.
Background FECA (5 USC 8101, et seq.) authorizes federal civilian employees
compensation for wage loss and medical and death benefits for treatment
of injuries sustained or for diseases contracted during the performance of
duty. OWCP is responsible for administering and adjudicating the federal
workers? compensation program. 2 During fiscal year 2000, OWCP?s paid
workers? compensation totaled about $2.1 billion including wage loss,
2 OWCP is also responsible for adjudicating and administering claims
authorized by the Longshore and Harbor Workers? Compensation Act, which
covers employees engaged in maritime employment, and for recipients of black
lung compensation. In addition, OWCP administers the Energy Employees?
Occupational Illness Compensation Act.
medical, and death benefits stemming from job- related injuries and OWCP
received approximately 174, 000 new injury claims.
A workers? compensation claim is initially submitted to an OWCP district
office and is evaluated by a claims examiner. The examiner must determine
whether the claimant has met all of the following criteria for obtaining
benefits: The claim must have been submitted in a timely manner. An
original
claim for compensation for disability or death must be filed within 3 years
of the occurrence of the injury or death.
The claimant must have been an active federal employee at the time of
injury.
The injury, illness, or death had to have occurred in a claimed accident.
The injury, illness, or death must have occurred in the performance of
duty. The claimant must be able to prove that the medical condition for
which compensation or medical benefits is claimed is causally related to the
claimed injury, illness, or death. Since medical evidence is an important
component in determining whether an accident described in a claim caused the
claimed injury and if the claimed injury caused the claimed disability,
workers? compensation claims are typically accompanied by medical evidence
from the claimant?s treating physician. Considerable weight is typically
given to the treating physician?s assessment and diagnosis. However, should
the OWCP claims examiner
conclude that the claimant?s recovery period seems to be outside the norm or
that a better understanding of the medical condition is needed to clarify
the nature of the condition or extent of disability, the examiner may obtain
a second medical assessment of the claimant?s condition. In such instances,
a second opinion physician, who is selected by a medical
consulting firm contracted by an OWCP?s district office, reviews the case,
examines the claimant, and provides a report to OWCP.
If the second opinion physician?s reported determination conflicts with the
claimant physician?s opinion regarding the injury or condition, the claims
examiner determines if the conflicting opinions are of ?equal value.? 3 If
the claims examiner considers the two conflicting opinions to be of equal
value, OWCP appoints a third or ?referee physician? to evaluate the claim
and render an independent medical opinion.
Claims may be approved in full or part, or denied. For example, a claimant
may be paid full wage loss benefits and provided physical and vocational
rehabilitation services, but denied a request for a medical procedure. When
all or part of a claim is denied the claimant has three avenues of recourse:
(1) an oral hearing or a review of the written record by the Branch of
Hearings and Review (BHR), (2) reconsideration of the claim decision by a
different claims examiner within the district office, or (3) a review of the
claim by the Employees Compensation Appeals Board (ECAB).
Under the first appeal option, the claimant can request an oral hearing or a
review of the claim?s written record by a BHR hearing representative. At an
oral hearing, the claimant can testify in person, be represented by a
designated representative, or submit written evidence. The employing agency
may attend but not participate unless invited to do so by the BHR
hearing representative or the claimant. For either a hearing or review of
the record, the hearing representative decides whether to affirm the initial
decision, reverse the initial decision and administer benefits to the
claimant, or remand the claim to the district office for a new decision.
A second option to the claimant is to request reconsideration of the
decision at the district office. During reconsideration, the district office
reevaluates its initial decision and the decision- making process to ensure
that it properly considered all facets of the claim. This reconsideration is
typically performed by a senior claims examiner who played no role in making
the original decision. After the entire record and resulting decision are
reevaluated, the claims examiner decides whether to affirm the initial
decision denying all or part of the claim or to modify the initial decision.
3 OWCP?s regulations state that to determine if the medical evidence is of
equal value, each physician?s opinion is to be considered against the
following factors: (1) whether the physician involved in the case is a
specialist in the appropriate field relevant to the claimant?s injury or
illness, (2) whether the physician?s opinions are based upon a complete and
accurate medical and factual history, (3) the nature and extent of findings
on examination of the claimant, (4) whether the physician?s opinions are
rationalized, and (5) whether the physician?s opinion is stated
unequivocally and without speculation.
Generally the final appeal available to the claimant is made to the ECAB.
The ECAB consists of three members who are appointed by the secretary of
labor. The board was created within DOL but outside OWCP to give federal
employees the same administrative due process of law and appellate review
that most nongovernment workers enjoy under workers? compensation laws in
most states. While regulations prohibit the claimant from submitting new
evidence during this phase, the ECAB is not limited by previous ?findings of
fact? by the district office or BHR and can therefore reevaluate the
evidence and determine if the law was appropriately applied. As with the
other appeals levels, ECAB renders decisions that affirm the district
office?s decision, remand all or part of the claimant?s appealed decision to
the district office for additional review, or reverse the district office?s
decision.
While OWCP regulations do not require claimants to exercise these three
methods of appeal in any particular order, certain restrictions apply that,
in effect, encourage claimants to file appeals in a specific sequence- first
going to the BHR, then requesting another review at the OWCP district
office, and finally involving the ECAB. For example, the regulations state
that a claimant seeking a BHR hearing on a decision must not have previously
requested reconsideration of that decision regardless of whether the earlier
request was granted. However, the BHR director said that claimants may, and
sometimes do, choose to request a district office reconsideration first
because the decisions on claims appealed through reconsideration are made in
a more timely manner. 4 Not withstanding the regulatory provision, OWCP
explained that a claimant may request a discretionary oral hearing by BHR
after receiving a reconsideration decision and both OWCP procedures and ECAB
precedent require OWCP to exercise its discretion in considering such a
request.
Appendix I contains a graphic presentation of OWCP?s claims adjudication
process. Scope and
We performed our work in Washington, D. C., from March 2001 through
Methodology
April 2002 in accordance with generally accepted government auditing
standards. To assist us in addressing the objectives, we reviewed a
statistical sample of more than 1, 200 of the estimated 8, 100 appealed
claims 4 Our sample and analysis focused on decisions by the BHR and ECAB on
appealed claims. We did not include requests for reconsideration by district
offices.
for which a decision was rendered by OWCP?s BHR or DOL?s ECAB during the
period from May 1, 2000, through April 30, 2001, to determine the following:
(1) the primary reasons why appealed decisions were reversed or claims were
remanded to the OWCP district offices for further development, (2) the
amount of time OWCP took to inform claimants of hearing decisions, (3)
whether OWCP used certified and licensed physicians whose areas of specialty
were consistent with the injuries evaluated, and (4) the methods OWCP uses
to identify customer satisfaction and potential claimant fraud. Additional
information on the scope and methodology of our review and approaches for
addressing these and other objectives is presented in appendix II and
confidence intervals and other statistical information regarding our work
are presented in appendix III.
Evaluation Problems, From May 1, 2000, to April 30, 2001, decisions were
rendered by BHR or
Case File ECAB on approximately 8,100 appealed claims. BHR or ECAB affirmed
an
estimated 67 percent of these initial decisions as being correct and
properly Mismanagement, and
handled by the district office, but reversed or remanded an estimated 31 New
Evidence Are
percent of the decisions 5 -25 percent because of questions or problems
Reasons Appealed
with OWCP?s review of medical and nonmedical information or management of
claims files, and 6 percent because of additional evidence
Claims Decisions Are being submitted by the claimant after the initial
decision.
Reversed or Remanded The following figure characterizes the outcome of BHR
and ECAB reviews
of appealed claims. For those claims decisions that were reversed or
remanded, the figure shows the reason, including (1) evaluation of evidence
problems, (2) mismanagement of claims file problems, or (3) new evidence
submitted by the claimant.
5 The remaining 2 percent of the decision summaries we examined did not
include information regarding what decision was reached on the claimant?s
appeal or the rationale for the decision.
Figure 1: Percentage of Appealed Claims Decisions Affirmed, Remanded, and
Reversed by BHR or ECAB during Period from May 1, 2000, through April 30,
2001
2% Case file management problem
4% 6%
Claimant submitted new evidence 21%
Evidence evaluation problem 67% No problem/ no change to decision
Affirmed Reversals and remands Cannot tell
Source: GAO analysis of ECAB and BHR appealed claims decisions.
About One- fourth of the Based on a statistical sample of appealed claims
decisions made during the
Appealed Claims Decisions period May 1, 2000, through April 30, 2001, we
estimate that 25 percent of
Were Reversed or the appealed claims decisions (approximately 2,000 of 8,
100) were reversed Remanded Due to OWCP
or remanded because of questions about or problems associated with the
initial decision by OWCP. These included problems with (1) the initial
Evaluation Problems or
evaluation of medical evidence (e. g., physicians? examinations, diagnoses,
Claims File Mismanagement
or x- rays) or nonmedical evidence (e. g., coworker testimonies) or (2)
management of the claim file (e. g., failure to forward a claim file to ECAB
in a timely manner). Problems in evaluating medical evidence frequently
involved OWCP failing to properly identify medical conflicts between the
conclusions of the claimant?s physician and OWCP?s second opinion physician,
and therefore not appointing a referee physician as required by FECA. OWCP
has interpreted the FECA requirement to apply
only when the opinions of the two physicians involved are of equal value,
that is, when both physicians have rendered comparably supported findings
and opinions.
Other initial claims decisions were reversed or remanded when BHR or ECAB
determined that nonmedical evidence had not been properly evaluated. One
example of this involved the OWCP provision that when suitable work is found
for the claimant, benefits will terminate. For example, based on its review
of a job offer to a claimant who had work restrictions- such as not being
able to lift over 50 pounds- an OWCP district office decided that the job
represented suitable work and
terminated the claimant?s compensation. However, when that decision was
appealed by the claimant, BHR identified a flaw in the job offer. In order
for OWCP to meet its burden of showing that an offered job is suitable for a
claimant, both the duties and physical requirements of the job need to be
fully described in the job offer. For this claim, the job offer had only set
forth the duties, such as inputting social security numbers on a keyboard.
The BHR representative decided that the offer did not describe the physical
requirements associated with the job and thus, did not ?allow the district
office to properly determine whether the offered job was suitable work
within the claimant?s work restrictions.? BHR concluded that the district
improperly terminated the claimant?s compensation and directed that the
claimant?s monetary compensation be reinstated. We estimate that 21 percent
of appealed claims were remanded and reversed due to problems with
evaluating medical or nonmedical evidence.
Some remands and reversals result from OWCP failing to administer claims
files in accordance with FECA or OWCP guidance for claims management. The
guidance includes (1) a description of the information that is to be
maintained in the claim file and transmitted by OWCP to the requestor (i.
e., BHR or ECAB) and (2) requires claims files to be transmitted within 60
days after a request is received. Failure to meet this 60- day requirement
was one of the more common deficiencies in claims file management in our
sample. For example, ECAB initially requested a claim file for one injured
worker from OWCP on April 29, 2000. On December 19, 2000 (almost 8 months
later), the Board notified OWCP that the claim file had not been transferred
and that if the file was not received within 30 days, ECAB
would issue orders remanding the case to the relevant district office for
?reconstruction and proper assemblage of the record.? As of March 12, 2001-
more than 10 months after the initial ECAB request -the claim file had still
not been transferred and the claim was remanded back to the
district office. We estimate that 4 percent of appealed claims were reversed
or remanded by the BHR or ECAB for claims file management problems. For
claims that were initially denied and then the decisions were reversed by
the BHR or ECAB due to problems identified with the initial evaluation of
evidence or mismanagement of claims files, there are delays in claimants
receiving benefits to which they were entitled. According to OWCP, the
average amount of time that elapsed from the date an appeal was filed with
BHR or ECAB until a decision was rendered was 7 months and 18 months,
respectively, in fiscal year 2000. Thus, while claimants are provided
benefits retroactively to the date of the initial decision when a claim is
reversed, they may be forced to go without benefits for what can be extended
periods and may have to incur additional expenses, such as representatives?
fees, during appeals that are not reimbursable.
New Evidence Submitted We also found that 6 percent of appealed claims
decisions were reversed or after OWCP Rendered
remanded because of new evidence being submitted by the claimant after
Decision Also Resulted in the initial decision was made. OWCP regulations
allow claimants to submit Reversals and Remands
new evidence to support their claims at any time from the rendering of the
initial claim decision until 30 days- or more with an extension- after the
BHR hearing or review of the record occurs. 6 Additional evidence could
include medical reports from different physicians or new testimonial
evidence from coworkers that in some significant way were expected to modify
the circumstances concerning the injury or its treatment and make the
previous decision by OWCP now inappropriate. Upon appeal of the earlier
district office decision, the BHR representative determines whether the new
evidence is sufficient to remand the claim back to the district office for
further review, or to reverse the initial decision. OWCP Has Taken Some
OWCP monitors remands and reversals by the BHR and ECAB to identify Actions
to Identify and
certain trends in appeals decisions. Steps OWCP says it takes include
Address the Causes of
reviewing ECAB decisions and preparing an advisory calling claims Reversals
and Remands
examiners? attention to selected ECAB decisions which may represent a
pattern of district office error or are otherwise instructive. Where more
notable problems are identified through ECAB reviews, a bulletin
6 Most reversals and remands resulting from the claimants submitting new
evidence were made by the BHR.
describing the correct procedures may be issued or training might be
provided. While OWCP similarly monitors reasons for BHR reversing and
remanding claims decisions, this information, or any suggested corrective
actions are not disseminated to claims examiners in as systematic a
manner as is done for ECAB decisions. Clearly, these actions are providing
some information on remands and reversals, which might be helpful to OWCP
and its district offices. However, this information is not fostering a full
understanding of the underlying reasons for remands and reversals occurring
at their current rates and what other actions might be taken to address
those factors. For example, OWCP might detect that a district office is
failing to appoint referee physicians when required. OWCP might then notify
district offices that such a problem was occurring, but with the information
currently available, it would not be able to identify how frequently the
problem was occuring or the underlying reasons- (1) are inexperienced claims
examiners not sufficiently aware of the requirement for a referee physician
when a conflict of medical opinions of equal value occurs, or (2) are
examiner?s experiencing difficulty in determining whether two physicians?
opinions were of equal value? Without such information on causes, it would
be difficult to address these problems.
We believe that OWCP needs to examine the steps now being taken to determine
whether more can be done to identify and track specific reasons for claims
decision remands and reversals. With such information, OWCP may be able to
act to address those underlying causes and in so doing, reduce remand and
reversal rates.
OWCP officials told us that they have not conducted such an overall
examination of its current process. Instead OWCP said they continue to
adjust their monitoring and communication process (circulars and bulletins)
based on available information. Finally, OWCP indicated that the
rate of OWCP remands and reversals was similar to that of other compensation
organizations. They provided us a comparison of four organizations whose
rates were similar or greater than theirs; the four were
DOL?s Black Lung Program, the Social Security Administration?s Disability
Program, and the North Dakota and Washington states? workers? compensation
programs. Except for the SSA program, no information was provided nor do we
have information concerning how comparable the programs are; thus we cannot
determine the validity of such a comparison. Regarding SSA, their reversal
rate may not be comparable to OWCP?s because of considerable emphasis on SSA
physicians? testimony for initial
claims decisions and the claimants? and their physicians? testimony during
adjudication hearings, resulting in high reversal rates. 7
OWCP Has Established FECA requires that OWCP notify claimants in writing of
hearing decisions
a Hearing Standard ?within 30 days after the hearing ends.? OWCP?s
interpretation of the
hearing process allows up to 110 days before almost all claimants are to be
That Allows 110 Days notified of decisions.
for Claimant In establishing guidelines for meeting this provision of the
act, the BHR
Notification director told us that the hearing record is not closed until
two separate but
concurrent processes are completed. 1. Printing and reviewing of hearing
transcript: The time needed to print
and review the hearing transcript could range from as few as 25 days to as
many as 47 calendar days from the hearing date. A contractor prints the
hearing transcript, which generally takes from 5 to 7 calendar days. 8 The
claimant and the claimant?s employing agency then review the
transcript of the hearing for up to 20 calendar days. If the employing
agency provides comments, OWCP provides the claimant with the 7 Social
Security Disability: SSA Must Hold Itself Accountable for Continued
Improvement in Decision- making (GAO/ HEHS- 97- 102, Aug. 1997).
8 The hearing transcript is generally a verbatim description of the hearing
proceedings and only on rare occasions includes a preliminary decision by
the BHR.
agency's comments and an additional 20 calendar days to respond to those
comments.
2. Submitting new evidence: OWCP gives the claimant 30 calendar days from
the date of the hearing to submit additional medical evidence. If the
claimant needs additional time to provide more medical evidence, the
regulations allow the OWCP hearing representatives to use their discretion
to grant a claimant a one- time extension period, that may be for up to
several months. OWCP officials stressed the importance of all the evidence
being considered before a decision is made since if the decision is appealed
to ECAB any subsequent review by the ECAB is limited to the evidence in the
claim record at the time of the preceding decision. Given the potentially
wide variance in the number of days before OWCP
can close a hearing record, an OWCP official said they have attempted to
establish realistic standards for notifying claimants of hearing decisions.
OWCP has established two goals for the timing of notifying claimants of
final hearing decisions: (1) notifying 70 to 85 percent of the claimants
within 85 calendar days, and (2) informing 96 percent of claimants within
110 calendar days following the date of the hearing. Based upon our review
of the applicable legislation, we determined that OWCP has the authority to
interpret the FECA requirement for claimant notification in this manner.
Of an estimated 2,945 appealed claims for which BHR rendered a decision on a
hearing during our review period, notification letters for an estimated
2,256 (or 77 percent) were signed by OWCP officials within 85 days of the
date of the hearing and an estimated 2, 716 (or 92 percent) of the claims
were signed within 110 days of the hearing date. 9 OWCP officials signed an
estimated 158 (or 5 percent) of the claimants? notification letters from 111
to 180 days after the hearing date and 70 claims (or 2 percent) from 181 to
more than 1 year after the hearing date. 10
9 Our analysis reflects only appeals for which necessary dates were
available in the claims decision files. We estimate that the dates we used
to determine the length of time required to provide decision information to
a claimant were available in the decision files for 95 percent of the BHR
appeals with hearings.
10 The percentages of claims decision notifications signed within 110, 111
to 180, and 181 days or more of the hearing date do not total 100 percent
due to rounding.
OWCP?s Physicians Our review showed that OWCP referee physicians were board
certified and
Were Board Certified, licensed in their specialties. In addition, we found
that OWCP?s second
opinion and referee physicians had specialties that were appropriate for
Licensed, and Had
claimant injuries in nearly all the cases we examined. Specialties
Consistent with the Injuries Examined
Most of OWCP?s Physicians Although neither FECA nor OWCP?s procedures manual
require second
Were Board Certified and opinion physicians to be board certified, the
procedures manual states that
Had State Medical Licenses OWCP should select physicians from a roster of
?qualified? physicians and
?specialists in the appropriate branch of medicine.? The manual further
requires that for referee physicians ?the services of all available and
qualified board- certified specialists will be used as far as possible.? The
manual allows for using a noncertified physician in special situations,
stating ?a physician who is not board- certified may be used if he or she
has special qualifications for performing the examination,? but the OWCP
medical official making that decision must document the reasons for the
selection in the case record.
Based on our statistical sample, we estimate that at least 94 percent of
OWCP?s contracted second opinion physicians and at least 99 percent of the
contracted referee physicians were board certified. 11 In making these
determinations, we used information from the American Board of Medical
Specialties (ABMS), the umbrella organization for the approved medical
specialty boards in the United States. In addition, OWCP provided
documentation verifying certifications of some of the physicians in our
sample. 12 For the remaining 6 and 1 percent of the second opinion and
referee physicians in our sample, respectively, we lacked information to
determine whether they were or were not certified.
Although neither FECA nor OWCP regulations specifically require either
second opinion or referee physicians to be licensed by the state in which
they practice, OWCP officials stated that OWCP expects that all physicians
will have state medical licenses. Based on our sample of physicians, we
estimated that at least 96 percent of the second opinion physicians and at
least 99 percent of the referee physicians had current state medical
licenses. For the 4 and 1 percent of the remaining physicians respectively,
we did not have sufficient information to determine whether or in what
state they were licensed. Second Opinion and Referee
An estimated 98 percent of OWCP?s second opinion and referee physicians
Physicians Had Specialties
appeared to have specialties relevant to the types of claimant injuries they
That Were Relevant to evaluated. While there is no requirement for referee
physicians to have
Injuries Evaluated specialties relevant to the types of injuries evaluated,
OWCP officials told
us that a directory is used to select referee physicians- with appropriate
specialties- to examine the type of injury the claimant incurred. For the
remaining physicians in our sample, that is the remaining 2 percent, the
11 We were only able to search for board certification and licensing for-
and consequently only included in our sample- those physicians for whom we
could identify a first and last name and an area of medical specialty from
the claims decisions summaries. Our estimates regarding board certification
and licensing cover about 63 percent of second opinion and 85 percent of
referee physicians.
12 One reason why neither OWCP nor we were able to determine if a small
proportion of physicians- for whom we had the necessary information (i. e.,
first and last name and specialty)- were board certified and state licensed
is that some of the medical examinations by the physicians in our sample
occurred during or prior to the period from May 1, 2000, through April 30,
2001. Each of the state medical boards and the ABMS web sites that we used
to check the status of the board certifications and licenses only provided
information on current status.
conclusion was that they had specialties which were not appropriate for the
type of injuries examined. For example, a cardiologist- acting as a second
opinion physician- examined a claimant for residuals of hypertension that
were aggravating the claimant?s kidney disease. The
claimed injury appeared to be associated with kidney rather than heart
disease. Therefore, it would have been appropriate for the claimant to be
treated by a nephrologist (kidney specialist).
For assistance in reviewing relevancy of physician specialties, we
contracted with a Public Health Service (PHS) physician. With that
assistance, we were able to review our sample of claimants? injuries and the
board specialties of the physician( s) who evaluated them to determine
if the knowledge possessed by physicians with a specific specialty would
allow them to fully understand the nature and extent of the type of injury
evaluated. 13 OWCP Uses Several
OWCP uses surveys of randomly selected claimants and focus groups to Methods
to Identify
monitor the extent of customer satisfaction with several dimensions of the
claims program, including responsiveness to telephone inquiries. OWCP
Customer Concerns
claims examiners and employing agencies serve as primary information and
Assists DOL?s IG in
sources for identifying potentially fraudulent claims. When such potential
Addressing Potential
fraud is detected, DOL?s IG investigates the circumstances and, if
appropriate, prosecutes the claimants and others involved.
Claimant Fraud 13 We were not able to attempt to evaluate the
appropriateness of the physician?s specialty in comparison to the injury for
some claims because the claims decisions summaries did not contain the type
of injury or the physician?s specialty. We estimate that the information
needed to evaluate the appropriateness of the specialty was available in the
summaries we used for an estimated 61 percent of second opinion physicians
and 83 percent of referee physicians.
Customer Satisfaction with OWCP obtains information concerning customer
satisfaction with the
the Claims Process handling of claims through surveys of claimants and
conducting focus
groups with employing agencies. Since 1996, OWCP has used a contractor to
conduct customer satisfaction surveys via mail about once each year to
determine claimants? perceptions on several aspects of the implementation of
the workers? compensation program, including overall service, for example,
whether claimants knew their rights when notified of claims decisions and
the timeliness of written responses to claimants? inquiries. 14 The
questionnaires did not include questions specific to the appealed claims
process, but some of the respondents may have based their
responses on experiences encountered when appealing claims. In the 2000
survey, customers indicated a 52 percent satisfaction rate with the overall
workers compensation program, and a 47 percent dissatisfaction rate. 15 The
level of claimant satisfaction indicated in their responses for specific
issues in the surveys have been largely mixed (i. e., more positive
responses for some questions and more negative responses
for other questions). For example, survey responses in fiscal year 1998
showed that 34 percent of the respondents were satisfied with the timeliness
of responses to their written questions to OWCP concerning claims, while 63
percent were not, and 35 percent were satisfied with the promptness of
benefit payments, while 26 percent were not satisfied. Based on these and
previous survey results, OWCP took actions including
creating a committee to address several customer satisfaction issues, such
as determining if the timeliness of written responses could be improved. 16
In fiscal year 2001, OWCP took two additional steps to measure customer
satisfaction. First, OWCP used another contractor to conduct a telephone
survey of 1, 400 claimants focused on the quality of customer service
provided by the district offices. As of March 25, 2002, a contractor was
still
evaluating the results of this survey. Second, OWCP held focus group
meetings with employing agency officials in the Washington, D. C., and
14 The claimants were selected on a random sample basis and the surveys were
conducted in 1996, 1997, 1998, and 2000. 15 The remaining 1 percent did not
provide information on overall satisfaction level.
16 Prior GAO testimony (Office of Workers? Compensation Programs: Goals and
Monitoring Are Needed to Further Improve Customer Communications, GAO- 01-
72T, Oct. 3, 2000) addresses deficiencies in the goals OWCP set for customer
satisfaction and the evaluative data collected for measuring progress in
improving customer satisfaction.
Cleveland, Ohio, district offices? jurisdictions. An OWCP official stated
that this effort provided an open forum for federal agencies to express
concerns with all aspects of OWCP service. In the Washington D. C. focus
group, employing agency officials expressed their belief that some of the
claims approved by OWCP did not have merit. The report on that meeting did
not specify whether this concern applies to appealed claims decisions. The
report documenting the Cleveland focus group effort indicated that employing
agencies were frustrated about not being informed of OWCP claims decisions
and several agencies said they continued to put through medical bills only
to be told by the employees that their claims had been denied.
OWCP Examiners and the The DOL?s IG- using information from claims examiners
and other
DOL IG Monitor Claimant sources- monitors, investigates, and prosecutes
fraudulent claims made Fraud
by federal workers. The IG?s office provides guidance to claims examiners
for identifying and reporting claimant fraud, including descriptions of
situations or ?red flags? that could be potentially fraudulent claims. Red
flags include such items as excessive prescription drug requests and
indications of unreported income. DOL?s Audits and Investigations Manual
requires claims examiners and other employees to report all
allegations of wrongdoing or criminal violations- including the submission
of false claims by employees- to the IG?s office.
Once a potentially fraudulent claim is identified, the IG will review
information submitted by the claimant, coworkers, physicians, and others.
The IG may also conduct additional investigations of claimants and medical
providers suspected of defrauding the program, such as surveillance of
claimants and undercover operations aimed at determining if a physician is
knowingly participating in fraudulent claims. For example, an IG agent-
wearing a transmitter- might pose as a postal worker and visit a doctor who
has been identified as providing supporting opinions for OWCP claimants with
questionable injuries. The agent could then tell the doctor that the claim
of injury is in fact false but that they need time off for personal reasons,
for example to get married. If the doctor agrees to support such a false
claim, the doctor would then be charged with fraud. Of approximately 600,000
workers? compensation claims filed with district offices from fiscal years
1998 through 2001, the IG opened 513 investigations involving potential
fraud. Of these, 212 led to indictments and 183 resulted in convictions
against claimants and physicians. 17 Conclusions One out of four OWCP
initial claims decisions (approximately 25 percent)
was either reversed or remanded upon appeal because of questions about or
problems with either OWCP?s evaluation of medical and nonmedical evidence or
improper management of claims files. For the appealed claims that were
eventually reversed because of problems with the initial decision,
benefits to which claimants were entitled are delayed. While benefits are
usually granted retroactively in such cases, going without those deserved
benefits for what might be extended periods might create hardships for
claimants. Further, representatives? fees and some other additional expenses
that claimants might incur during the appeals process are generally not
reimbursed by OWCP.
While OWCP monitors certain information on BHR and ECAB remands and
reversals to identify problems in district office decisions, and distributes
much of this information to district offices, that information does not
fully identify underlying causes of the problems. An examination of the
monitoring steps OWCP is currently taking and a determination of what other
information could help OWCP and its district offices to address underlying
causes could result in a reduction of the rate of remands and reversals.
17 A number of the cases involved more than one claimant or physician.
Recommendation for We recommend that the secretary of labor require the
director of OWCP to
Executive Action examine the steps now being taken to determine whether more
can be
done to identify and track specific reasons for remands and reversals-
including improper evaluation of evidence and mismanagement of claim files-
and address their underlying causes.
Agency Comments and We obtained comments on this report from the Assistant
Secretary for
Our Evaluation Employment Standards, Department of Labor. The Assistant
Secretary
agreed with our conclusions regarding the timing of notifying claimants on
hearing results; physician certification, licensing and specialties; and
processes used by OWCP to monitor customer satisfaction and potential
claimant fraud. The Assistant Secretary raised concerns, however, with our
conclusions related to the frequency of and reasons for reversals and
remands of initial OWCP claims decisions when appealed by the claimant.
Following is a presentation of key comments from the Assistant Secretary and
our responses to those comments.
OWCP Comment
A principal comment regarding the report and its conclusions relates to the
use of BHR and ECAB decision summaries to determine the rate of remands and
reversals due to (a) introduction of new information, (b) mismanagement of
case files and (c) district office problems in
evaluating claim evidence. In short, OWCP asserts that BHR and ECAB summary
decisions are inadequate to make such determinations. The Assistant
Secretary also expresses the belief that a ?large portion? of decisions that
our review showed were reversed or remanded because of questions about or
problems with the initial decision (as opposed to new evidence being
submitted), were in fact reversed or remanded because of new evidence being
submitted. GAO Response
We disagree. Decision summaries we reviewed clearly indicated specific
reasons for each reversal or remand and our analysis fully accounted for
remands and reversals that were ordered by the BHR and ECAB due to the
introduction of new information by the claimant. For example, in the summary
of one decision remanded by the ECAB due to an evidence evaluation problem,
the BHR had originally decided that a claimant was not entitled to benefits.
The BHR decision was based on a second opinion
physician?s report and several reports from the claimant?s two physicians?
all of which preceded the BHR decision. The BHR ?representative found that
the opinions of the (claimants) attending physicians could not be afforded
any great weight as their opinions were based on the fact that the
(claimant) was performing duties requiring repetitive shoulder movements,
and this was not true.? In remanding the decision, ECAB determined that
there were ?discrepancies between the opinions of the (claimant?s
physicians) and the (second opinion physician) that there is a conflict in
the medical opinion evidence as to the cause of the (claimant?s) current
condition and, therefore, the case will be remanded? for the appointment of
a referee physician. An example of a decision where new evidence was
submitted, was an ECAB decision summary that stated that the decision was
remanded back to the OWCP district office ?because (claimant) submitted
relevant and pertinent evidence not previously considered by the office.?
OWCP Comment
Cases are frequently reviewed by claims examiners on arrival and may be
remanded if late arriving evidence is sufficient to meet the claimant?s
burden of proof. These claims examiner remands prior to hearing are
frequently based on the review of evidence not available to the district
office examiner. It appears that the GAO investigators entirely excluded
these cases from their sample.
GAO Response
OWCP is incorrect. Our sample, as indicated in our report, was drawn from
all appealed case decisions made during a 1- year period and therefore
encompassed all affirmations, remands and reversals that were made before
hearings, after hearings and those for the record during that 12 month
period. OWCP Comment
The percent of appeals reversed or remanded by the ECAB may be the purest
indicator of district office oversight or error.
GAO Comment
We note that, based on our sample, the rate of ECAB remands and reversals
was approximately 23 percent, which closely approximates the composite
remand and reversal rate for both BHR and ECAB of 25 percent.
OWCP Comment
The report also conflates its analysis of remands and reversals. Remands and
reversals must be distinguished. A remand does not reverse the denial of a
claim and direct the examiner to pay the denied benefit. It may, for
example, direct the examiner to ask further questions of the reporting
physician, after which the district office issues a new decision that
considers the doctor?s further response. The new decision may reinstate the
original denial or award the benefit.
GAO Response
We have added wording to our report to make the distinction clear. However,
because our analysis focused on the same issue for both, i. e. questions
about or problems with initial claims decisions made at OWCP district
offices, we believe it is appropriate to use reversals and remands as a
combined indicator.
OWCP Comment
In summary, the report?s presentation of the ratio of remands and reversals
caused by new evidence, as opposed to ?errors? in the original decision, is
seriously flawed. We have attached a chart that provides the actual outcomes
from the two appeal bodies for FY 2001. Following the actual procedures we
have described, we believe that all (BHR) decisions in which a hearing was
held reflect new information to some degree. As for
the other categories, our experience is that half the remands/ reversals
prior to hearing and most of the remands/ reversals following reviews on the
record are based on the submission of new evidence. This analysis yields the
conclusion that well over half of the (BHR) remands/ decisions reflect the
consideration of new evidence or new argument. GAO Response
We agree that new evidence is submitted and considered in many cases
throughout the life of a claim, which may involve a number of separate
appeals. However, our review of decision summaries clearly showed the
reasons for remand or reversal of initial claims decisions when appealed.
Those reasons, which also were provided to claimants in explaining why the
decision on their claim was being remanded or reversed, included (1)
questions about or problems with the availability or consideration of
evidence at the time of the initial decision, or (2) problems with case file
management; and (3) new evidence or information being introduced. The chart
provided by OWCP does not present any information on such specific reasons
for remands and reversals. In fact, in response to our request for such
specific information at the end of our review, we were told by OWCP
officials that OWCP did not have such information.
OWCP Comment
The report characterizes four percent of cases as due to ?mismanagement of
claim files.? This phrase is not defined and only one example is offered.
With no definition and only one example, the phrase ?mismanagement? appears
to be unsupported.
GAO Response
We believe the discussion concerning ?mismanagement of claim files?
adequately defines the issue. In addition, the example provided is for
illustrative purposes. OWCP Comment
GAO?s recommendation appears to be based on (1) the substantial
overestimation of the contribution of OWCP errors to the remand/ reversal
rate and (2) a generalization that no systematic study of the ?underlying
causes? of remands and reversals has been undertaken by OWCP. OWCP explained
its many and varied approaches to decision monitoring and quality
improvement to the GAO team, and we do not understand the basis for this
generalization. In fact, OWCP does react to data showing trends from ECAB
decisions and hearing decisions, provides appropriate training to claims
examiners, and is fully committed to continuing to monitor the outcomes of
appeals.
GAO Response
While we agree that OWCP takes a number of actions to monitor decision
reversals and remands, and in fact we recognize many of these in our
report, our estimates of the rates and reasons for remands and reversals are
statistically valid. Our recommendation is based upon (1) the importance of
ensuring that claimants receive benefits to which they are entitled as
promptly as possible; (2) the level of initial claims decision remands and
reversals upon appeal; and (3) our conclusion that there may be
opportunities for OWCP to better identify the reasons for and address the
underlying causes of remands and reversals.
OWCP Comment
GAO acknowledged the basis for OWCP?s application of a hearing standard
which allows for 110 days for hearing decision notification, including time
for the claimant?s review of testimony and opportunity to comment.
GAO Response
Our report describes how OWCP has interpreted the FECA requirement and
established a target of notifying most claimants of the decision on their
appeal within 110 days of the date of the hearing. We did not assess whether
this is an appropriate target.
Finally, DOL indicated that, consistent with our recommendation, they would
review and enhance their systems for monitoring results of its claims
adjudication process ?to better achieve improvements in our claims review.?
DOL also provided technical comments which we incorporated in the report as
appropriate. DOL?s comments are reprinted in appendix IV.
As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days after
the date of this letter. At that time, we will send copies to the ranking
minority member and to the secretary of labor. We will also make copies
available to others on request at that time.
Major contributors to this report were Boris Kachura, Assistant Director;
Thomas Davies Jr., Project Manager; Ellen Grady, Senior Analyst; Chad
Holmes, Analyst; and Karen Bracey, Senior Operations Research Analyst.
Sincerely yours, George H. Stalcup Director, Strategic Issues
Appendi Appendi xes x I
OWCP?s Claims Process Based on interviews with OWCP officials and reviews of
OWCP operational guidance, when a federal employee is injured at work and
becomes disabled, the employee files a claim with the employing federal
agency. All claims that involve medical expenses or lost work time or both
are then forwarded by the agency to 1 of OWCP?s 12 district offices. 18
Figure 2 characterizes OWCP?s claims process, including the claims
adjudication process.
18 For uncontested traumatic injury claims, if the claim is for medical
expenses that did not exceed $1, 500 and the employee missed less than 45
days of work as a result of the injury, an OWCP claims examiner can
reimburse the claimant for the medical expenses incurred and provide the
claimant with continuation of pay benefits. An OWCP official said the claims
examiner would then administratively close the claim without a determination
of entitlement.
Figure 2: Claims Process Initial claim adjudication process
Injured federal
no
Claimant chooses employee files a
to appeal through
1
claim with the reconsideration by
employing agency the district office
Claimant chooses Does the
no
to appeal through claim involve
no
an oral hearing or
2
medical expenses Claim is not filed
a review of the and/ or time
with OWCP written record to
the BHR b loss?
yes a
Is the
no
Claimant chooses claimant satisfied
a review by ECAB
3 District Office
with the entire Claim is filed with
Does the decision?
district office
no
Claim/ part of the district office for
approve the entire claim denied
a review by a claims claim?
examiner
yes
Claimant does
no
Claimant does
yes
not further not appeal the
appeal the decision
Claim a pproved decision
and benefits administered
Claims appeal/ review process Reviewing office/ agency Possible outcomes
Next steps
District office
Claimant chooses to
1 Claim is reconsidered Does
yes
Claim/ part of claim appeal through
1
the district office denied reconsideration again to
See by a different claims
the district office examiner
claims examiner affirm the appealed
no
Claim approved and decision?
benefits administered Claimant does not appeal
the decision
2
Claimant chooses to appeal through the ECAB
See
3
Claimant chooses to
3
appeal through See
1 yes
Claim/ part of claim reconsideration to the
denied district office
BHR
Decision is reversed Claimant does not appeal
Does and claim is remanded
the decision Hearing representative
the hearing
no
to district office for the conducts hearing and
representative affirm administration of
reviews the claim the appealed
benefits Claimant chooses to
decision? appeal to the ECAB
See
3
Case file is
no
remanded to district office for the case to be further developed; claim may
or may not be approved
yes
Claim/ part of claim Claimant does not appeal
denied the decision c
Decision is reversed and claim is remanded
ECAB
Does the
no
to district office for the Claim is reviewed by
ECAB affirm administration of
a 3- member board the appealed
benefits decision?
Case file is remanded to district
no
office for the case to be further developed; claim may or may not be
approved
a A portion of uncontested traumatic injury claims are administratively
closed without a determination of entitlement, which allows for continuation
of pay and limited medical expenses. b The appellant loses the right to a
hearing before a BHR representative if a reconsideration has already been
conducted by the district office. However, BHR has the discretion to hear
the matter. c By law, claims can not be appealed to the U. S. Federal Court
of Appeals, outside of DOL.
Source: GAO review of OWCP?s claims process.
Appendi x II
Scope and Methodology In your March 2001 letter, you asked GAO to examine
several issues related to OWCP?s workers? compensation claims adjudication
process. To meet this objective, we reviewed a probability sample of over
1,200 decision summaries from about 8,100 ECAB and BHR claims appeal
decisions made between May 1, 2000, and April 30, 2001, on claimant appeals.
As part of our review of the decisions made by BHR and ECAB on appeals,
we first categorized the decisions in our sample into three groups: (1)
affirmed (the decision made on the initial claim was not changed), (2)
remanded (the claim was sent back by either ECAB or the BHR to the cognizant
district office for additional review or action and a new decision), or (3)
reversed (the initial decision made on the claim by the district office or
BHR was determined by BHR or ECAB to be incorrect and was therefore changed-
in most cases a claim or portion of a claim that had been denied was changed
to an approval). For each claim that had
been remanded or reversed, we then analyzed the decision summaries to
determine the basis for the BHR or ECAB decision. To determine the extent to
which OWCP was complying with FECA?s requirements that (1) a referee
physician be appointed to resolve conflicts
in medical opinions between claimant physicians and OWCP?s second opinion
physicians and (2) claimants be informed of the outcome of hearings in a
timely manner, we performed several steps. For the first of these two
objectives, we reviewed FECA legislation and
OWCP regulations and interviewed OWCP officials to identify the specific
requirements related to referee physicians. From our statistical sample of
claims appeal decisions, we then identified decisions in which at some point
during the history of the claim, there had been a conflict in the medical
opinions between the claimant?s attending physician and an OWCP second
opinion physician. For this subset, we relied upon the decisions of the BHR
and ECAB as reflected in decision summaries to determine the extent to which
referee physicians were appointed as required. In addition, we identified
the frequency that claims were remanded or reversed by the
BHR and ECAB because a referee physician should have been but was not
appointed.
Regarding the length of time taken by OWCP to notify claimants about hearing
outcomes, we reviewed the relevant FECA requirement and OWCP?s guidelines
and goals and interviewed OWCP officials. We limited our review on this
objective to claims decisions rendered by BHR, because ECAB decision
summaries did not contain the dates needed for our
analysis. Accordingly, we selected a subset of BHR cases from our sample,
and calculated the number of days between the date of the hearing and the
date of the final hearing decisions. In making our calculation, we used the
date of the BHR decision letter as the claimant notification date.
To determine whether the physicians involved in reviewing claims were board
certified, we used another subset of claims appeal decisions from our
sample, and relied on information from the American Board of Medical
Specialties? (ABMS) website (www. abms. org). ABMS is the umbrella
organization for approved medical specialty boards in the United States. We
compared the names and specialties of the second opinion and referee
physicians to the database to determine whether these physicians were board
certified. We looked for an exact or close match of names while allowing for
obvious spelling errors in the name or other minor discrepancies, such as
missing initials. Although most of the board certification verifications
were done by querying the ABMS website and printing copies of the
certifications, when necessary we also contacted ABMS by telephone to obtain
verbal verification on board certifications or used ABMS? directory book for
calendar year 2002. For those physicians whose certifications we were not
able to readily verify, we asked OWCP to provide documentation of the board
certifications, which they did for a number of physicians. In determining
whether second opinion and referee physicians used by
OWCP had state licenses, we used the same sample subset as we used in
verifying board certifications. In making the state license determinations,
we generally focused on the state in which the employee resided for BHR
decisions, and the state in which the employing agency was located in for
ECAB decisions. We relied on a variety of resources in that search,
including www. docboard. org (a public service site) and individual state
medical board web sites for printed documentation. We also phoned staff in
various state medical board offices for verbal confirmation for some
physicians. We again looked for an exact or close match of name while
allowing for spelling and other minor differences. In addition, since
physicians are required to have state medical licenses in order to become
board certified, any physicians whom we could not verify as licensed
through state sources were considered to be licensed if we had determined
the physicians were board certified. Also, while the dates of physician
involvement on individual cases could have taken place anytime during or
even preceding the May 1, 2000, through April 30, 2001 period of our review,
we made our determinations for state licenses as of December 31, 2001.
We also determined whether second opinion and referee physicians contracted
for by OWCP possessed the appropriate medical specialty to evaluate and
fully understand the nature and extent of the claimant?s particular illness
or injury. To do this, we drew another subset of the
appealed claims decisions for which we could determine that a second or
referee physician was involved, and that we could identify the nature of the
claimant?s injury and the physician?s medical specialty. We contracted with
a Public Health Service (PHS) physician to review the injuries of the
claimants in this sample and determine whether the board specialties of the
physician( s) who evaluated those injuries were appropriate. 19 To determine
how OWCP identifies problems with its appeals process,
levels of customer satisfaction, and potential claimant fraud, we
interviewed OWCP officials- including the deputy director and director of
BHR- and reviewed documentation provided by OWCP, including reports from
several annual customer (claimant) surveys and focus groups of federal
agencies. In addition, we interviewed officials in DOL?s IG, analyzed IG
guidance on detecting and investigating potential fraudulent activity, and
reviewed IG annual reports that discussed the identification and prosecution
of claimant fraud.
We did our work in Washington, D. C., from March 2001 through April 2002.
Our work was done in accordance with generally accepted government auditing
standards.
19 We were not able to evaluate the appropriateness of the physician?s
specialty in comparison to the injury for some claims because the decision
summaries did not contain the type of injury or the physician?s specialty.
Sampling and Estimation Methods and
Appendi x III
Sampling Errors To help accomplish some of our objectives we reviewed a
probability sample of over 1,200 ECAB and BHR decisions issued between May
1, 2000, and April 30, 2001. This appendix describes how we selected
decisions for review and provides the sampling error of estimates presented
in this report that we made from our sample.
ECAB and BHR cases were sampled separately. We obtained a list of ECAB
decisions issued between May 1, 2000, and April 30, 2001. The listed
decisions were classified as either remands or nonremands and a simple
random sample of each of the two classifications was selected. BHR decision
files covering the period of our review were stored in folders in three
filing cabinets. Each folder was divided into two compartments. We took
separate systematic samples from the front and back compartments
of the folders in the cabinets. Since the file cabinets contained some
decisions that fell outside our review period, we estimated, based on our
sample, the number of decisions in the three filing cabinets that were
issued between May 1, 2000, and April 30, 2001.
Using these sampling methods described above, we obtained a sample of over
1, 200 decisions. Each sampled decision was weighted in our analysis to
account statistically for all appealed claims decisions issued between May
1, 2000, and April 30, 2001, including those that were not sampled. The
estimates we made from our sample and the sampling errors associated with
these estimates are given in the table below.
Table 1: Sampling Error of Estimates for Appealed Claims Decisions to ECAB
and BHR between May 1, 2000, and April 30, 2001 a Sampling error of
Confidence Description Estimate
estimate interval Result of BHR/ ECAB appeal review
a. Percent of decisions that were affirmed 67 � 2 65- 69 b. Percent of
decisions that were reversed 10 � 2 8- 12 c. Percent of decisions that were
remanded 22 � 2 20- 24 d. Percent of decisions where review result could not
be determined 1 � 1 0- 1 e. Percent of decisions that were remanded or
reversed due to questions about or problems with
25 � 2 23- 27 case management or evaluation problems f. Number of decisions
that were remanded or reversed due to questions about or problems with
2,026 � 174 1,852- 2, 201 case management or evaluation problems g. Percent
of decisions that were remanded or reversed due to new evidence 6 � 1 5- 7
Physicians? board certification and licensing
a. Percent of second opinion physicians reviewed for board certification and
licensing 63 � 4 59- 68 b. Percent of referee physicians reviewed for board
certification and licensing 85 � 8 77- 94 c. Percent of second opinion
physicians who were board certified 94 � 3 91- 96 d. Percent of referee
physicians who were board certified 99 � 1 98- 100 e. Percent of second
opinion physicians who were licensed 96 � 2 94- 98 f. Percent of referee
physicians who were licensed 99 � 1 98- 100
Relevance of physician specialty to claimant injury
a. Percent of second opinion physicians reviewed for appropriateness to
claimant injury 61 � 4 57- 65 b. Percent of referee physicians reviewed for
appropriateness to claimant injury 83 � 8 75- 91 c. Percent of second
opinion and referee physicians who had appropriate specialties for the
claimed
98 � 1 96- 99 injuries Claimant notification time after hearing
a. Percent of hearing summaries reviewed 95 � 2 93- 97 b. Number of appealed
claims in which an oral hearing was held and BHR rendered a decision on
2,945 � 71 2, 874- 3, 015 between May 1, 2000 and April 30, 2001 c. Percent
of claimants notified of hearing outcome in less than or equal to 85 days 77
� 4 72- 81
d. Number of claimants notified of hearing outcome in less than or equal to
85 days 2,256 � 199 2,057- 2, 456 e. Percent of claimants notified of
hearing outcome in less than or equal to 110 days 92 � 3 89- 95 f. Number of
claimants notified of hearing outcome in less than or equal to 110 days
2,717 � 202 2,515- 2, 918 g. Percent of claimants notified of hearing
outcome in 111 to 180 days 5 � 2 3- 8 h. Number of claimants notified of
hearing outcome in 111 to 180 days 158 � 65 93- 223 i. Percent of claimants
notified of hearing outcome in 181 days to more than 1 year 2 � 1 1- 4 j.
Number of claimants notified of hearing outcome in 181 days to more than 1
year 70 � 44 26- 114
a Sampling error and confidence intervals are based on the 95 percent
confidence level. Source: GAO analysis of appealed claims decisions.
Appendi x IV Comments from the Department of Labor
(450027)
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a
GAO United States General Accounting Office
Page i GAO- 02- 637 Workers' Comp Programs
Contents
Contents
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Page 1 GAO- 02- 637 Workers' Comp Programs United States General Accounting
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Appendix I
Appendix I OWCP?s Claims Process
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Appendix I OWCP?s Claims Process
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Appendix I OWCP?s Claims Process
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Appendix II
Appendix II Scope and Methodology
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Appendix II Scope and Methodology
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Appendix III
Appendix III Sampling and Estimation Methods and Sampling Errors
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Appendix IV
Appendix IV Comments from the Department of Labor
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Appendix IV Comments from the Department of Labor
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Appendix IV Comments from the Department of Labor
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Appendix IV Comments from the Department of Labor
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Appendix IV Comments from the Department of Labor
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Appendix IV Comments from the Department of Labor
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United States General Accounting Office Washington, D. C. 20548- 0001
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