Training Resources
Training Resources
The very best narrative reports can often result in denied OWCP claims. Doctors must be willing to relentlessly fight for their patients’ rights to get help after a work injury. That means that when patients receive denials, doctors must respond to the denials in the form of written narratives. These narratives could be short or lengthy. They could be addendums to the original narrative, or they could be modifications to the original.
Some doctors feel that writing new narratives isn’t fair. They’re not getting paid yet because the claim isn’t accepted. Sometimes, multiple denial responses are required. Doctors could get very upset about this. In order to be considered a top OWCP doctor, getting legitimate claims approved, no matter the effort required, must be made a top priority.
Here’s the good news: all legitimate timely filed claims should be ultimately approved. Legitimate means that the injury is actually work-related. Timely filed means that the injury was reported within 3 years of the injury, or in the case of a CA2, 3 years from the time the patient was reasonably aware the condition was work related.
When claims are denied, the claims examiner mails a denial letter to the patient’s residence. Patients should always be instructed to bring in all DOL letters to the office for someone in the office to review. Denial letters contain valuable information, especially one or more paragraphs that specifically detail the reason for the denial.
Doctors should identify the reason for the denial, from the letter, and respond to it in writing, in the form of a narrative report. This written response is then sent into the claims examiner using ECOMP.
The denial letter sent to the patient also contains a document called, “Appeal Request Form”. Patients should select “Reconsideration” and submit that to their claims examiner. This allows the claims examiner to consider the new information contained in the doctors denial response letter. Patients have 12 months from each denial date to send in a reconsideration using new information from their doctor that addresses the denial.
Anytime the patient / doctor does not meet the 5 basic elements of an accepted claim, the claim will be denied. An extraordinary narrative covers all 5 elements in great detail. However, when a claim is denied, a denial letter is mailed to the patient’s home. The doctor needs to read this letter and find the section explaining specifically why the claim was denied and then respond to it in written form. Many denials are ridiculous, but all denials need to be overcome with another beautiful narrative from the doctor. When the new narrative is complete, ecomp it to the claims examiner and tell the patient to send in their Appeal Request Form and respond in writing as to why they are requesting reconsideration. The claims examiner will consider the new information submitted by the doctor and make a new decision based on that new data.
The most common denial is from the doctor not showing detailed causation. Many doctors can prove a diagnosis with imaging and other testing and it’s generally easy to explain that an incident occurred or that a person has worked at a very repetitive job over a long period of years. The problem is that most doctors fail to connect the dots between the job and the diagnosis. You must show a direct link between the job and the injury / condition. This requires tremendous detail. It’s not enough to explain that a person is injured and it’s not enough to explain that they were hurt on the job. You have to explain exactly HOW it happened. What was the mechanism of injury? What exactly does a sprain mean? What is a herniation? What is carpal tunnel? And how were these things caused by the job. When you can do this effectively, your claims will be approved.
The next common denial is usually due to bad diagnoses. Pain diagnoses are always denied. No exceptions. Cervicalgia, Lumbago, and any other pain and other symptom diagnoses will be denied. Never use these diagnoses, ever. Instead, find the diagnosis that is causing those symptoms and diagnose that.
Weak Medical Opinion Statements: Your medical opinion statement, at the end of all narratives, will look like the following: “In my medical opinion, the following conditions are a direct result of the employees required job duties.” This sentence says that you’re an expert and that your medical opinion is definite – unequivocal, without doubt, absolute. Too many doctors (but never you) write weak statements like, “In all medical probability,” or “To a reasonable degree of medical certainty.” These weak statements will cause claims to be denied. You are a trained OWCP doctor. You are an expert. You’re certain about your diagnosis and causation. So, say so. Approved claims will follow.