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State of New York Workers


Title: State of New York Workers Compensation Board ; Bureau of Health Management Author: austind Last modified by: jan m Created Date: 12/10/2010 9:10:18 PM – PowerPoint PPT presentation

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Title: State of New York Workers

State of New York Workers Compensation Board
Bureau of Health Management
  • Monroe County Medical Society
  • January 19, 2011

  • Medical Treatment Guidelines
  • Overview of the history, background and goals of
    the Guidelines and the Boards implementation
  • Medical Directors Office
  • General Principles
  • Procedures that require pre-authorization
  • Variance Process
  • Optional Prior Approval Process
  • Prior Authorization for care not covered by the
    Medical Treatment Guidelines
  • Disputed Medical Bill Process
  • Other recent regulatory changes
  • Questions

Medical Treatment Guidelines
  • 2007 Legislation was adopted to reform NY
    Workers Compensation Laws.
  • The Governor created a Reform Task Force and
    appointed an Advisory Committee comprised of
    physicians and other medical professionals,
    attorneys, and representatives from business,
    labor, and the insurance industry to develop
    medical treatment guidelines.
  • October, 2008 Draft Guidelines published for
    review and comment Comments received through
    September, 2009.
  • November 30, 2009 Pilot project commenced to
    test the Draft Medical Treatment Guidelines
  • January, 2010 Revised Guidelines released.
  • June 30, 2010 Medical Treatment Guidelines,
    First Edition and the regulations are published.
    Comments on the regulations accepted through
    August 16th, 2010.
  • November 3, 2010 Notice of adoption posted on NY
    State Register

Medical Treatment Guidelines
  • Effective Date
  • gt For dates of service on, or after, December
    1, 2010, the Medical Treatment Guidelines became
    the mandatory standard of care for injured
    workers, regardless of the date of injury.
  • date coincides with the implementation of the
    revised Medical Fee Schedule.
  • gt Providers are required to treat all existing
    and new workers compensation injuries in
    accordance with the Guidelines.

Medical Treatment Guidelines
  • Mid Low Back Injury
  • Knee Injury

Neck Injury
The Medical Treatment Guidelines apply to
treatment of these injuries only
Shoulder Injury
Medical Treatment Guidelines
  • Why these 4 areas of the Body?
  • These areas of the body represent the most
    common and most costly workplace injuries.
    Together they account for 40 of workers'
    compensation claims and 60 of the system's
    medical costs.

Medical Treatment Guidelines
  • Goals
  • gt Establish a single standard of medical care.
  • gt Accelerate delivery of quality medical
    services for injured workers.
  • gt Improve medical outcomes.
  • gt Expedite return to work.
  • gt Reduce unnecessary medical care and overall
    system costs.
  • gt Reduce disputes resulting in timely payment to
    medical providers.

Medical Treatment Guidelines
  • Development of the Guidelines
  • American College of Occupational and
    Environmental Medicine and the State of Colorado
    guidelines (nationally recognized and evidence
  • Comments received and new scientific
    literature submitted to the Board.
  • Input from the Advisory Committee

Medical Treatment Guidelines
  • Transition to the Guidelines
  • Posting each revision of the Guidelines on the
  • Pilot Program
  • Worked with carriers and providers to refine the
  • Training
  • Outreach to Medical Providers (meetings,
    mailings, Board releases)
  • FAQs on the Web site
  • Release of Subject numbers
  • Navigation Software

Medical Treatment Guidelines
  • The Pilot Program
  • In November, 2009, the Board conducted a pilot
    program involving 1,000 actual workers
    compensation cases. Survey of participants
  • 90 agreed communication was improved between
    the carriers and the providers.
  • 85 agreed medical disputes were reduced.
  • 85 agreed the injured workers received faster
    access to medical care.

Medical Treatment Guidelines
  • Office of the Medical Director
  • Promote high quality care outcomes for
    injured workers
  • Implement and update the guidelines.
  • Provide guidance, advise assistance with the
    medical treatment impairment guidelines.
  • Meet with various parties to discuss medical
    issues related to workers compensation.
  • Educate guideline users.
  • Oversees the Health Provider Administration
  • Does not treat injured workers or perform
  • phone 1-800-781-2362

Medical Treatment Guidelines
  • Standard of Care
  • Medical care must be provided in a manner
    consistent with the Guidelines
  • 1) Treatment provided must in accordance with
    the recommendations in the Guidelines, and,
  • 2) Treatment is based on a correct application
    of the Guidelines (combines the General
    Principles with specific Guidelines

Medical Treatment Guidelines
  • The Guidelines do not apply if
  • 1) Emergent medical care is needed.
  • 2) The injured worker both resides outside of
    New York State and is treated outside of New York
    State (Also, the Guidelines do not apply for
    workers compensation cases under the
    jurisdiction of another state).
  • 3) Treatment is for other types of injuries and
    conditions other than the shoulder, knee, neck,
    and mid/low back.
  • 4) The injured worker is employed by an employer
    not within the Boards jurisdiction.

Not Within Jurisdiction of the Workers
Compensation Board
  • Uniformed Police Officers of
  • Auburn (prior to 7/1/07 and after 6/30/08)
    Buffalo, Elmira, Rochester, Rome, Syracuse,
    Utica, Watertown( Watertown officers may elect
  • Uniformed Firefighters of
  • Auburn (prior to 7/1/07 and after 6/30/08)
    Buffalo, Elmira, Rochester, Rome, Syracuse, and

Not Within Jurisdiction of the Workers
Compensation Board
  • Longshoreman, merchant seamen
  • All Federal employees including postal workers
    and U.S. Department of Labor employees and
  • Railroad employees
  • St. Lawrence Seaway employees

Medical Treatment Guidelines
  • General Guideline Principles
  • gt Medical Care
  • gt Treatment Approaches
  • gt Time Frames
  • gt Return to Work
  • To correctly apply the Medical Treatment
    Guidelines, the medical provider needs to
    understand the general guideline principles and
    how they work in conjunction with the Treatment
  • Two categories will be discussed Medical Care
    Treatment Approaches

Medical Treatment Guidelines
  • General Principles-Medical Care
  • Treatment focused on restoring functional
    capacity to meet the patients daily and work
    activities, and return to work.
  • Positive results defined as functional gains
    that can be measured.
  • Time frames for re-evaluation of treatment
    for patients in a rehabilitation program. If not
    is producing positive results, treatment should
    be modified or discontinued.
  • Provider must implement educational strategies
    which provide reassuring information to the
    patient (ie self-management of symptoms and
    future injury prevention).

Medical Treatment Guidelines
  • In the mid and low back guideline, therapeutic
    exercise, an active therapy, has a maximum
    duration of eight weeks. This treatment
    recommendation must be applied according to
  • - Principle 3 Positive Patient Response.
  • - Principle 4 Re-Evaluate Treatment.
  • Eight weeks of therapy are not automatically
    approved. The patient must be showing continuing
    functional improvement which must be included in
    the medical documentation.

Medical Treatment Guidelines
  • Re-Evaluations/Positive Patient Response
  • gt For patients in a rehabilitation program, a
    re-evaluation of the treatment must be performed
    2-3 weeks after the initial visit, and 3-4 weeks
    thereafter. If not is producing positive results,
    treatment should be modified or discontinued.

Medical Treatment Guidelines
  • Positive Patient Response
  • gt Positive patient response is measured by
    functional improvement that can be objectively
  • gt Objective functional improvement includes, but
    is not limited to, positional tolerances, range
    of motion, strength, endurance, activities of
    daily living, cognition, psychological behavior,
    and efficiency/velocity measures which can be

Medical Treatment Guidelines
  • General Principles-Treatment Approaches
  • Emphasize active interventions over passive
    modalities include patient responsibility and
    therapeutic exercise.
  • Passive interventions are a means to
    facilitate progress in an active rehabilitation

Medical Treatment Guidelines
  • General Principles-Treatment Approaches
  • Surgical interventions must be based on
    positive correlation of clinical findings,
    clinical course, imaging and other diagnostic
    tests. (ie To perform surgery for pain, there
    must be a clear correlation between the pain and
    the evidence of the cause).
  • All procedures that are based on a correct
    application of the Guidelines are considered
    pre-authorized except for the procedures clearly
    identified in the Guidelines.

Medical Treatment Guidelines
  • Insurance Carrier Responsibilities
  • gt Insurance carriers and self-insured employers
    are required to
  • Incorporate the treatment guidelines and the
    regulations into their procedures.
  • Certify their compliance with the Guidelines
    to the Workers Compensation Board, and report
    any changes in procedures.
  • Designate a contact person for optional prior
    approval, the variance, and the pre-authorization
    processes ( available on the Boards web site).
  • Designate a medical professional to review
    requests for optional prior approval and a
    variance ( M.D., PA, RN or NP).

Medical Treatment Guidelines
  • Pre-Authorization
  • Any treatment that is consistent with the
    Medical Treatment Guidelines is pre-approved and
    requires no action by the treating medical
    provider before providing the treatment.
  • Exceptions -12 specific procedures identified
    in the regulations and repeated surgical

Medical Treatment Guidelines
  • List of Procedures Requiring Pre-Authorization
  • Back and Neck
  • Artificial disk replacement
  • Electrical bone growth stimulators
  • Back
  • Lumbar fusions
  • Vertebroplasty
  • Kyphoplasty
  • Spinal Cord Stimulators
  • Shoulder
  • Anterior acromioplasty of the shoulder

Medical Treatment Guidelines
  • List of Procedures Requiring Pre-Authorization
  • Knee
  • Chrondoplasty
  • Osteochondral autograft
  • Autologus chrondocyte implantation
  • Meniscal allograft transplantation
  • Knee arthroplasty (total or partial knee joint
  • Also, the repeat performance of a surgical
    procedure due to failure of, or incomplete
    success from the same surgical procedure
    performed earlier, and if the medical treatment
    guidelines do not specifically address multiple
  • Use the December 1, 2010 version of the
    C- 4AUTH form when requesting authorization
    (Required for the MTG).

Pre-Authorization for Medical Care Not Covered by
the Treatment Guidelines
  • Authorization Request for Special Services
  • For specialist consultations, surgical
    operations, physiotherapeutic or occupational
    therapy procedures, x ray examinations, or
    special diagnostic laboratory tests, MRIs or
    other radiological exams costing more than
    1,000, providers must request prior
    authorization from the insurance carrier or self
    insured employer. (Must show medical necessity
    for the special service).
  • Use form C-4AUTH

Pre-Authorization For Medical Care
  • Denial of the Authorization Request
  • gt If the carrier denies the request for
    authorization it must submit
  • The C-4AUTH form submitted by the provider
    with carrier section completed.
  • A C-8.1 form, part A.
  • A conflicting second medical opinion (IME).
  • Disputes are resolved by the Board

Medical Treatment Guidelines
  • Guideline Reference Codes - Must be indicated on
    the MG-1, MG-2, and C-4AUTH forms.
  • Example For therapeutic exercise to the neck
  • Box 1 N for neck
  • Box 2 Section D for Therapeutic
  • Box 3. 10 for Therapy-Active under Section D
  • Box 4. g for Therapeutic Exercise under D.10

Medical Treatment Guidelines
  • Variance
  • It is recognized there are legitimate reasons
    for not adhering to the Guidelines
  • People heal at different rates.
  • Extenuating circumstances or co-morbid
    conditions may delay an individual's response to
    treatments or procedures.
  • Peer reviewed studies may provide evidence
    supporting new/alternative treatments.

The variance provides flexibility of the
Guidelines in order to address treatment that
varies from the MTG
Medical Treatment Guidelines
  • Variance
  • A variance request is necessary for a medical
    provider to provide treatment that is
  • gt Not consistent with the Guidelines
  • gt Not recommended by the Guidelines
  • gt Not addressed in the Guidelines
  • gt Involves more, or longer periods of treatment
    than allowed by the Guidelines.

Medical Treatment Guidelines
  • Requirements for all variances
  • gt Providers opinion on medical necessity.
  • gt The claimant agrees to the proposed medical
  • gt Provider explanation of why alternatives under
    the Guidelines are not appropriate or sufficient.

Medical Treatment Guidelines
  • Variance Requirements for the Individual Claim
  • gt The claimants signs and symptoms have failed
    to improve with previous treatment consistent
    with the Guidelines.
  • gt For frequency or duration of treatment,
    variances must demonstrate continued objective
    improvement for that treatment, and are expected
    to further improve with additional treatment.
  • gt The burden of proof to establish a variance
    rests on the treating medical provider. The
    provider must show that the treatment is
    appropriate and medically necessary. May submit
    citations or relevant literature published in
    recognized, peer-reviewed medical journals.

Medical Treatment Guidelines
  • Variance Forms
  • MG-2 Doctors Request for Approval of a
    Variance and Carriers Response. Filed by the
    provider with the carrier, the Board, and
    claimant or the claimants legal representative
    if represented.
  • MG-2.1 Continuation to form MG-2 when more
    than one testing or procedure is necessary which
    is outside of the Guidelines.

Medical Treatment Guidelines
  • Variance Process
  • gt Provider determines if treatment necessary is
    outside the Guidelines and requests a variance on
    form MG-2 and submits it to the appropriate
  • gt Carrier must respond to the Board and provider
    on form MG-2 within 15 calendar days if not
    requiring an IME or records review. (The carrier
    must respond even if the body part or the case is
    not established).
  • gt Carrier must notify the Board and the provider
    within 5 business days if requiring an IME or
    records review. Has 30 days to respond on form
  • gt The Board monitors the carrier response. If no
    response or not timely, the variance is deemed
    approved and an Order of the Chair is issued.

Medical Treatment Guidelines
  • Variance Process Carrier Denial
  • gt If the carrier denies the request, form MG-2
    is completed and sent to the various parties.
    Must state the reason(s) for the denial and
    indicate if they waive their right to a hearing.
    (The carriers medical professional must review
    the denial unless the provider failed to provide
    the needed burden of proof, the request was
    submitted post-treatment, or the injured worker
    failed to attend an IME).
  • gt The provider has 8 business days to attempt to
    resolve the issue with the carrier. If resolved,
    the carrier completes the form and sends to the
    various parties.

Medical Treatment Guidelines
  • Variance Process Carrier Denial
  • gt If unresolved, the provider notifies the
    injured worker who has 21 days from the date of
    the denial to request a review, and also indicate
    if they want to waive their right to a hearing.
  • gt If both the injured worker and the carrier
    waive their right to a hearing, the matter is
    decided by a medical arbitrator. If not, an
    expedited hearing is scheduled.
  • In a controverted case, a carrier can approve a
    variance request without assuming liability of

Medical Treatment Guidelines
  • Optional Prior Approval
  • Designed to provide a streamlined process for
    medical providers to receive confirmation from a
    participating carrier or self-insured employer
    that the requested treatment is consistent the
    treatment guidelines.
  • gt Carriers and self-insured employers can opt
    out of the optional prior approval process.

Medical Treatment Guidelines
  • Optional Prior Approval Forms
  • MG-1 Doctors Request for Optional Prior
    Approval and Carriers Response. Filed by the
    provider with the carrier and the Board.
  • MG-1.1 Continuation to form MG-1 when
    requesting that more than one procedure or test
    is based on correct application of the

Medical Treatment Guidelines
  • Optional Prior Approval Process
  • gt Form MG-1 is completed by the provider and sent
    to the appropriate parties (check to see if the
    carrier is participating in the process).
  • gt The carrier must approve or deny the request on
    form MG-1 within 8 business days of receipt (The
    carrier must respond even if the body part or the
    case is not established).
  • gt If no response, the test or treatment is deemed
    approved and the Board will issue a Notice of
    Resolution stating the request is approved.

Medical Treatment Guidelines
  • Optional Prior Approval Process Carrier Denial
  • gt If the carrier denies the request, the request
    had to have been reviewed by the medical
    professional, and the basis for denial stated.
    Form MG-1 is submitted to the medical provider
    and the Board.
  • gt Provider receives the denial, and may attempt
    to informally resolve with the carrier.
  • gt If resolved, carrier completes the section of
    the MG-1 form. If unresolved, the provider may
    request a review by the Board by completing the
    section on the form and submitting it within 14
    calendar days of the denial.
  • gt The medical arbitrator reviews and responds
    within 8 business days. Decision cannot be
    appealed, and carrier cannot dispute the bill.

Medical Treatment Guidelines
  • Payment of Medical Bills
  • The Payer is responsible for payment of all
    medical care (per fee schedule) that is
  • 1) Within the criteria of the Guidelines and is
    based on correct application of the Guidelines
  • 2) Based on an approved variance from the
  • 3) Agreed to by the payer
  • OR
  • 4) as ordered by the Board

Medical Treatment Guidelines
  • Carriers post-treatment objection to a bill due
    to Guideline Issues- 3 Reasons
  • 1) Treatment was an incorrect application of the
  • 2) Treatment deviated from the guidelines and no
    approved variance is present.
  • 3) The treatment exceeded an approved variance.
  • Carrier must file a C-8.1 form with the
    Board resolved through

Medical Treatment Guidelines
  • Navigation Software
  • gt Solicited vendors for navigation software for
    the Workers Compensation Board.
  • gt Will map diagnosis codes (ICD-9), appropriate
    procedure and testing codes (CPT), and Medical
    Fee Schedule to the correct section of the
  • gt Similar products will be available for
    carriers and medical providers that can be
    tailored for their use.

Medical Treatment Guidelines
  • The Future
  • The Guidelines are intended to be living
    documents and be updated over time as new medical
    technologies and processes are developed.
  • Guidelines will be developed for other types
    of injuries and conditions other than the
    shoulder, knee, neck, and mid/low back.

Medical Treatment Guidelines
  • Free Web-based Training
  • gt Treating physicians chiropractors (CME and
    CCE credits).
  • gt Attorneys and legal representatives (CLE
  • gt Non-medical staff such as insurance adjusters,
    medical provider office, billing companies, etc.

Medical Treatment Guidelines
  • Free Web-based Training
  • gt To Register
  • Click on Health Care Information
  • Click on Medical Treatment Guidelines
  • Click on Training
  • Select the Program you wish to take
  • Click on how to use this training
  • Choose click here to register
  • Complete the Registration Page
  • You will receive an e mail
  • Technical difficulty call 1-800-781-2362 option

Medical Treatment Guidelines
  • Web Site Changes New Section on the Guidelines
  • Frequently asked questions
  • The Guidelines, Regulations, Training
  • Board Subject numbers 046-270, 046-346,
    046-435, 046-444, 046-445, 046-449 046-456,
  • Search capability for providers to determine
    the carrier contacts for the various Guidelines

Medical Treatment Guidelines
  • To Obtain a Copy
  • Down load from web site
  • Submit Order Form to request paper copies or
    a CD
  • Information/Questions/Help
  • phone 1-800-781-2362 Option 1

Insurance Carrier Response to the Medical Bill
  • Carrier pays medical bill in full within 45 days
    of receipt of the bill, or within 30 days of a
    notice of decision in the case finding carrier
    liability for payment No further action.

Insurance Carrier Lack of Response to the Medical
  • Carrier does not respond to medical bill timely
    within 45 days of receipt of the bill, or within
    30 days of a notice of decision in the case
    finding carrier liability for payment. Provider
    may request an administrative award on HP-1 form.

Medical Provider
Insurance Carrier
HP-1 Form
Workers Comp. Board
Filing for an Administrative Award
  • No legal issues are present in the case.
  • Providers original signature.
  • One billing cycle per HP-1.
  • Include a copy of the original bill submitted
    (supporting narratives or office notes not
  • A minimum of 45 days has elapsed from the date
    the bill is received by the carrier, and no more
    than 120 days have elapsed since the expiration
    of time in which the carrier should have paid the

Insurance Carrier Response to the Medical Bill
  • The insurance carrier files timely (within 45
    days of receipt of the bill or within 30 days of
    a decision resolving a legal issue) a C-8.4 is
    submitted to the provider raising
    arbitration/valuation issues. Provider can
    request arbitration on HP 1 form.

Arbitration Issue Raised C-8.4 form
Request Arbitration HP-1
Arbitration/Valuation Issues
  • Amount of the medical bill is
  • Not in accordance with the fee schedule
  • Not properly pro rated or apportioned between
  • Not in accordance with ground rule limitation
  • Not correct for the particular CPT code (s)

Arbitration/Valuation Issues
  • Medical treatment
  • Is inappropriate
  • Involves concurrent or overlapping services
  • Is duplicative, excessive, or rendered too
  • Is unnecessary or excessive hospitalization
  • Is outside the scope of the provider

Filing Arbitration Request
  • Carrier objected timely, raising arbitration
  • Legal issues have been resolved.
  • Proper payment in accordance with the fee
    schedule has not been received.
  • Providers original signature.
  • Include a copy of the original bill(s) submitted,
    and any supporting narratives, office notes, or
  • Include the arbitration fee (listed on the HP-1
  • Include a copy of the insurance carriers written
    explanation of non-payment or partial payment
    (Must clearly state reasons).
  • Submit within 120 days of receipt of the
    insurance carriers written explanation of non
    payment or partial payment.

Judgment for Payment of Awards
  • Medical providers who are not paid after
    receiving an administrative award or an
    arbitration decision in their favor, may request
    consent to file judgment with the County Clerk.
  • For Administrative Awards or Arbitration
    decisions made on or after March 13, 2007.

Judgment for Payment of Awards
  • Wait 60 days after receiving the administrative
    award or arbitration decision.
  • Request Consent to File Judgment on HP-J1.
  • Attach a copy of the award(s) or arbitration
    decision(s). (6 awards maximum per HP-J1 must be
    same claimant and WCB ).
  • Complete the form thoroughly.
  • The medical provider must sign and date. (Must
    be notarized if signed by an authorized hospital
    representative, chiropractor, physical or
    occupational therapist, podiatrist or
    psychologist ).

Other Recent Regulatory Changes
  • Change the 45 day Reporting Rule
  • Medical Reporting requirements for medical
    providers has been increased to 90 days, from 45
  • gt Initial Visit C-4.0 48 hour report
  • gt Follow up C-4.2 15 days later
  • gt Continuing Treatment C-4.2 90 day report
    (maximum timeframe) should see patients as
    medically necessary and send reports.

Other Recent Regulatory Changes
  • Carrier Notice to the Health Care Provider of a
    Carriers Refusal to Pay All (or a Portion) of a
    Medical Bill Due to a Valuation Issue
  • C-8.4 form is required as of December 1, 2010.
  • Sent to the medical provider, the Board, and
    the claimants attorney (or the claimant if not
  • Carrier does not have to file a C-8.4 if the
    provider billed above the fee schedule, and the
    carrier reimbursed the provider at the fee

Other Recent Regulatory Changes
  • Medical Fee Schedule Updates
  • 30 increase to Evaluation Management Codes
  • Updated CPT codes
  • Regulations adopted effective December 1,
  • Copy of Fee Schedule Ingenix 1-800-464-3649

Form Changes December 1, 2010
  • C-4.0 - minor changes to the instructions
  • C-4.2- minor changes to the instructions change
    from 45 day progress report to 90 days.
  • C-4 AMR minor changes to the instructions
  • C-4 AUTH Significant changes due to MTG
  • C-5 minor changes to the instructions change
    from 45 day progress report to 90 days.
  • C-8.1 significant changes (a form for carriers)

Boards On-line Services for Providers
  • Providers can complete and submit C-4, C-4.2, and
    C-4.3 reports.
  • Providers can complete and submit the EC-4 NARR.
  • Automatic e mail notification of Board releases
    (subject numbers)
  • Employer insurance coverage lookup
  • List of authorized providers and IME entities
  • Common workers compensation terminology
  • Forms
  • Return to work handbook/ communication guide/FAQ
  • Medical impairment guidelines
  • Medical treatment guidelines

Resources For Medical Providers
  • gt Bureau of Health Management/Health Provider
    Administration (800)-781-2362
  • gt Board Customer Service (877) 632-4996
  • gt Board Fax Number (877)-533-0337
  • gt Rochester District Office (866) 211 0644

  • This presentation is intended to provide New
    York medical providers with general information
    regarding the States Workers Compensation
    Program. It is based on interpretation pursuant
    to the New York State Workers Compensation Law
    and Codes, Rules Regulations.
  • The presentation does not represent legal advise
    and is not a complete representation of the
    Workers Compensation Law. Only the Board, in the
    exercise of its adjudicatory function is
    authorized to determine entitlement to benefits
    based on the specific facts of a given claim and
    the application of law to those facts.