2020 EEOICPA Ombudsman Report to Congress Highlights

The Office of the Ombudsman for the Energy Employees Occupational Illness Compensation Program recently published its annual report to Congress for 2020. This report details the complaints the office received from the stakeholders and provides recommendations that would improve the program. The following is a summary of some of the issues and the Ombudsman’s recommendations.

Medical Benefits Issues

The report identified three major areas of concern for this issue:

• Complaints related to the medical billing contractor transition.
• Difficulties obtaining assistance with medical billing.
• Inadequate assistance with medical bill coding issues.

The complaints about the transition from one medical billing contractor to the present contractor, CNSI, has been pretty much resolved.  Those issues that occurred in 2020 included having the wrong compensation program listed on the some of the medical benefits card and the multiple changes to the mailing address.

Both claimants and providers reported issues concerning the lack of assistance when they run into billing issues.  The report provides an account of medical provider reaching out to the Ombudsman’s office for help,

Our Office also received a request for assistance and was provided copies of billing invoices from a dental practice for over $8,000 in unpaid bills related to covered treatment for claimants rendered from 2018 through 2020. The medical provider explained that they were not as familiar with the billing practices and forms used by DEEOIC, and that it had been four months since they were last able to communicate with the person they had previously spoken with at the DEEOIC Resource Center. The medical provider stated that several messages had been left but no one had called them back. We forwarded the billing invoices to DEEOIC and approximately seven months later were informed that DEEOIC and the medical provider were still working through the billing issues, with some of the outstanding billing issues having been resolved.

Recommendation to the program:  “Claimants and providers with medical billing issues should be quickly directed to someone who can assist them in resolving their issues. DEEOIC needs to ensure that there is an effective way to promptly direct those with medical billing issues to the personnel who can assist them.”

Impairment claims

There were two types of complaints brought to the Ombudsman’s attention regarding impairment claims.  One concern was the application of a waiver of the 2-year waiting period before a new impairment rating can be processed and the other is the Chief Medical Director’s involvement in impairment evaluations.

The program allows a claimant to file a new impairment claim if a new condition has been accepted and involves a different organ system (heart versus lung, for example) or if a worker’s covered condition has deteriorated significantly since the last impairment rating that they are not able to perform daily activities as they once did.

The issue was not only that the request for a new impairment was denied but the authorized representative was given confusing guidance by the claims examiner that conflicted with the Procedure Manual.

Recommendation:  “…some DEEOIC staff would benefit from further guidance on these topics. Not only would additional training assist in specific cases such as the ones reported to our Office, but would also likely result in greater consistency among impairment claims where claimants are seeking increased impairment benefits.”

The other complaint about impairment claims was submitted by both an authorized representative (AR) and the physician who performed the impairment evaluation.  According to the AR,

What we are seeing is that when [the rating physician] writes an impairment review, they are almost always being sent to the ‘National Office’ for review by the DEEOIC Medical Director Dr. Armstrong who always states the Impairment wasn’t conducted in accordance with the 5th Edition AMA guidelines. This happens virtually every time [the rating physician’s] report his [sic] Dr. Armstrong’s desk. Dr. Armstrong or the CE sends it back and [the rating physician] is forced to write an amended review which takes substantial time on his part and he always is careful to refute Dr. Armstrong’s claims line by line.

Recommendation:  “At a minimum, it would be helpful to claimants and the physicians performing impairment evaluations for them to have a full explanation regarding why the reports are being rejected, sometimes even after the physician provides an amended report.”

The report also addresses other complaints,

• Effectiveness of outreach efforts.
• Difficulties understanding the claims process.
• Customer Service.
• Other complaints including issues with Industrial Hygienists and Contract Medical Consultant reports.