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RED FLAGS
You Should Watch For BEFORE Your OWCP Claim For
A Scheduled Award Is Filed

 
PLEASE READ
We have just learned (6/8/09) that OWCP has started using the AMA Guides 6th Edition. Until we can update all of our resources please understand that wherever the AMA Guides 5th Edition is written here, just know that the AMA Guides 6th Edition is now required. PEN

It has been brought to our attention that your OWCP claim for a schedule award may contain RED FLAGS that may be viewed by a claims examiner as an indicator that your claim may, in their opinion, contain incomplete, inconsistent, inaccurate, or other type information indicating to them that they may want to challenge your claim.

OWCP may consider items listed below as Red Flags to Erroneous Impairment Ratings:

  • Your impairment rating was performed by your regular physician or your treating physician.

    It seems that claims examiners have greater confidence in your claim if your rating has been provided by someone other than the physician who treated you for your injury - or the injury for which your claim addresses.
     

  • Your rating fails to point out specific figures, tables, and/or page numbers that can be found in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition.

    Your ratings physician should make a point to reference specific figures, tables, or page numbers from the AMA Guides 6th Edition.
     

  • MMI or Maximal medical improvement has not been properly defined in your claim or your impairment rating was performed prior to one year from date of injury.

    Obviously, it seems that claims examiners give less credit to your claim if your physician states that you have reached MMI and one year has not lapsed since your injury occurred.  A scheduled award cannot be filed until you have reached MMI or maximum medical improvement. Your claim must address when you reached MMI.
     

  • The AMA reference book titled “AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition” has not been indicated in your claim by your ratings physician.

    The vast majority, if not all, impairments ratings - best known as PPI ratings - must come directly from the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition. If your physician has not indicated in your claim that he/she derived their ratings from this AMA reference book please make certain to have this corrected before filing.
     

  • Your ratings physician references the term "disability" when he/she should be referencing "impairment".
     

  • Your ratings physician fails to document an adequate clinical evaluation and analysis as specified in the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition.


The items above are but a few of the RED FLAGS that claims examiners look for in your claim for a scheduled award. We're certain others exist - if you know of any please Contact PEN.

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