MEDICAL BILL PROCESSING

Medical Payment
Direct Payment to Medical Providers
Reimbursements of medical payments for an employee's accepted condition

Medical Payments

Medical payments may be paid either by the USPS or OWCP. The USPS pays medical bills for the following:

• First-aid cases treated by USPS contract medical providers.
• Management directed medical services, e.g., FFDs, consultative examinations, and tests.

Medical bills arising from these visits, including first-aid visits, may include office visits, X rays, lab work, pharmaceutical bills, and miscellaneous medical expenses. OWCP pays for all medical bills from a job-related injury or illness for which a CA-1 or CA-2 is filed.

The Federal Employees' Compensation Act provides that an employee shall be entitled to receive all medical services, appliances or supplies which are prescribed or recommended by a duly qualified physician and which the Office of Workers' Compensation Programs (OWCP) considers necessary for the treatment of an accepted job-related injury. Charges for authorized medical and surgical treatment, appliances or supplies furnished to injured employees should be submitted to OWCP for payment.

Submission of a bill without a compensation claim number and date of injury may result in a significant delay in processing or return of the bill for further information. The provider should ask the injured worker for his/her claim number, and insure that it is included on all billings or correspondence. If the injury was recently sustained and the injured worker has not received a claim number, OWCP recommends that the provider withhold submission of the bill until a number has been received.

Bills for medical treatment may not be paid if submitted more than one year beyond the calendar year in which the employee's claim was first accepted as compensable by OWCP.

When a Form CA-16 has been issued by the Postal Service to a qualified physician or hospital of the employee's choice, the physician/hospital is authorized to furnish treatment as medically necessary for the effects of this injury, including non-invasive testing (i.e., MRI, CT Scan, EMG, etc...) Any surgery or invasive procedure other than emergency must have prior OWCP approval.

Payment for medical and other health services furnished by physicians and other persons for work-related injuries or conditions may be limited by the U.S. Department of Labor's schedule of maximum allowable charges.

Since June 9, 1986, a schedule of maximum allowable medical charges has been applied to medical charges from certain provider types. For example, a claimant goes to a physical therapist for treatment. The therapist bills OWCP $50.00 for the visit. OWCP does not automatically pay the entire $50.00; rather, the therapist's zip code and the CPT code used for the service provided govern the amount of money he/she will receive based upon comparison to an elaborate computerized model which sets a limit of compensable fees based upon all bills paid for the same CPT code in the provider's zip code. The fee schedule is designed to guarantee that the provider of a service in a certain geographic area is billing a reasonable amount for the services provided.

A provider MAY NOT seek from the patient any additional charge or fee in excess of the charged allowed by OWCP. For example, if OWCP paid the above therapist $35.00 for services rendered, the therapist could not bill the claimant for the additional $15.00. If a provider disagrees with an amount of a reduction under the fee schedule, he/she must follow the directions supplied in the appeal rights that accompany the reduced payment.

Please note that the fee schedule is also applied to claimant reimbursements. In other words, if a claimant paid the therapist's charge of $50.00 and then requested reimbursement from OWCP his/her bill would be bound by the fee schedule and he/she would only be reimbursed the $35.00 allowable amount.

The following is a brief checklist that should be referred to when submitting bills to OWCP for payment or reimbursement and an overview of the Bill Processing System that is used by OWCP.

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Direct Payment to Medical Providers

1. A medical provider may only submit bills for the accepted work related condition. If an employee's claim has been accepted for a right ankle sprain, OWCP should not receive bills for a low back sprain. Bills for non-work-related conditions are not payable by OWCP.
2. All providers (doctors, physical therapists, etc.) must submit bills on a HCFA-1500 form. All providers are familiar with this form as it is universally used to bill private insurance as well. Bills an injured worker receives at home are most likely not on the HCFA-1500 form and should not be submitted to OWCP as they are not payable in that format and will only be returned. The HCFA-1500 is not required for treatment and supplies provided by hospitals, pharmacies, ambulance services and nursing homes.
3. The provider's Federal Tax Identification Number (also known as the EIN number) must appear on the bill along with the full street address, to include zip code. The HCFA-1500 should also include the provider's ink signature or facsimile stamp.
4. Hospitals must submit fully completed bills on a UB-82 or the updated UB-92 form. Once again, bills an injured worker receives at home from the hospital are most likely not on this form and should not be submitted to OWCP. A copy of the discharge summary should be submitted with the bill from the hospital.
5. Pharmacy, ambulance service, nursing home, and medical supply bills may be itemized on the provider's billhead stationary or a HCFA-1500. Bills for prescription drugs must include the generic or trade name of the drug, the quantity, prescription number, zip code, the date the prescription was filled, the federal tax ID number and indicate whether the claim(s) is for charge or reimbursement.
6. Chiropractic care is only payable when the accepted condition is a subluxation of the spine. Furthermore, only office visits, x-rays and manual manipulation are covered by OWCP. All other charges will be denied.
7. Each bill must show the condition treated, the date of service, and the treatment performed. Bills submitted with the phrase "Balance Forward" are not payable.
8. Providers must include the International Classification of Diagnosis codes (ICD-9) and the AMA Current Procedural Terminology code (CPT) to describe each service provided for each day of treatment. They may NOT use the state workers' compensation codes. Dentists, visiting nurses, hospital inpatient care and medical appliances, such as orthotics, do NOT require coding but must be approved by OWCP in advance.
9. Physical therapy bills must be itemized by date and have a separate line item with specific CPT code for each modality.
10. A provider's bill should only show itemized services that are not yet paid.
11. The provider should routinely submit office notes and medical records for visits. Failure to do submit these records may cause non-payment of an otherwise payable bill if questioned by an examiner.
12. The employee's case file number must appear on the bill.

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Reimbursements of medical payments for an employee's accepted condition

1. The claimant must submit a fully completed HCFA-1500 or UB-82 (or UB-92) form along with proof of payment. This is required for all reimbursements including but not limited to the attending physician, therapist, supplier (for appliances such as canes or orthotics), or hospitals.
2. Proof of payment consists of photocopies of the front and back of the canceled check or credit card receipt, a computer generated statement showing patient payment, or a paid receipt with the full address from the provider.
3. The bills claimants submit for reimbursement have the same requirements as those submitted by the provider listed above.
4. Pharmacy (drug) reimbursements are made by submitting the original label from the prescription which must include the name of the drug, dosage, prescribing doctor and claimant's name, along with the pharmacist's certification of payment from the claimant.
5. Travel vouchers may only be submitted for obtaining medical treatment or supplies (wheelchairs, canes, etc...) and not prescription drugs (unless the trip to the pharmacy is made in conjunction with a trip for medical treatment). The voucher must include the origin, destination with time, number of miles, and reason for travel. Travel other than directly to and from treatment is not payable. Tolls or parking will not be paid without original receipts. All travel vouchers will be matched with provider dates of service.

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