This is Part 2 of a 2 Part Article. Be sure to check out Part 1
Longshore OWCP Medical Fee Schedule
The Office of Administrative Compensation Programs for the United States Department of Labor has an OWCP Medical Fee Schedule. In order to have the Administrative Law Judge approve your medical bills you will need to prove that the bills and/or rates charged are consistent with the Office of Workers Compensation Programs (OWCP) Medical Fee Schedule.
In a similar vein, the employer (in most instances this is actually the Longshore/ / DBA/ NAFIA/ OCSLA insurance company) will only approve your bills up to the OWCP Medical Fee Schedule.
The federal regulations state that medical fees by medical providers shall be limited to that which prevails in the community. When a dispute arises (as it always does), the OWCP Medical Fee Schedule shall be used to determine the prevailing reasonable and customary charge. Where the OWCP Medical Fee Schedule does not establish a rate, other state or federal fee schedules, or prevailing community rates may be used.
Thus, the prevailing community rates can only be used when the OWCP Medical Fee Schedule does not establish a rate.
The OWCP Medical Fee Schedule uses geographic adjustment factors (also called geographic practice cost index values (GPCI) to each reimbursement. The fee schedule is applicable to charges for services by medical professionals, including physicians, clinical psychologists, ophthalmologists, chiropractors, osteopaths, podiatrists, physicians' assistants, therapists, and medical technologists/ technicians.
It applies to inpatient services, out patient services, anesthesia services, ambulatory surgical centers, implanted medical equipment, prosthetics, prescription drugs, home health services.
Medical provider can’t collect excess amounts from the patient/ claimant
Once the medical provider is paid under the OWCP system, the medical provider is not allowed to request reimbursement from the injured employee/ patient/ claimant for any amount in excess of the maximum allowable. You don't want to go here - bad stuff can happen if you do - very bad stuff.
The Devil is in the Details
How this plays out in the real world is two fold. In the first scenario the insurance company approves medical treatment and then the medical treatment is provided and then bills are sent to the insurance company which then disputes the bill based upon a variety of reasons, one being it is in excess of the OWCP Medical Fee Schedule.
The other scenario is when treatment is provided that was not authorized (say the claim is denied or it was emergency medical care).
In either scenario in order to get paid you will either have to negotiate with the insurance company or go to formal hearing in order to have your medical bills paid. Or both - nothing gets these issues settled better than facing a formal hearing. This is because the insurance company has to pay a lawyer to fight the medical bills and will have to pay the claimant’s (or the medical provider’s) attorney if it loses. This assumes that the proper procedure was followed, which is not always the case.
Much more problematic is when the case is accepted and authorization was not requested and the treatment was not emergency in nature.
Even when the insurance company agrees to pay a medical provider, you can rest assured that it will come back to the Medical Fee Schedule. This is where the devil in the detail arises.
You will need to go through the bill with a fine tooth comb in order to assure that you were properly paid. While this is usually in the purview of the medical provider, there needs to be communication with the claimant’s counsel. In other words, if you aren’t getting paid correctly, let the claimant’s attorney know this as early as possible. This is because this has to be raised at both the informal conference and formal hearing (trial).
This all comes back to making sure the claimant has seasoned attorney well versed in Longshore / DBA/ NAFIA/ OCSLA cases.
For more information
For more information you should visit and get acquainted with the OWCP medical fee schedule information on the US Department of Labor’s website. However, keep in mind that much of the procedure and rules discussed there applies to Federal Employees Compensation Act (FECA) claims and not claims under the Longshore / DBA/ NAFIA/ OCSLA.
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