State of New York Workers’ Compensation Board ; Bureau of Health Management. Board Meeting February 15, 2011. Medical Treatment Guidelines. Administrative Overview Overview of the history, background and goals of the Guidelines and the Board’s implementation process.
February 15, 2011
> 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.
> Providers are required to treat all existing and new workers’ compensation injuries in accordance with the Guidelines.
> Low & Mid back
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.
> Establish a single standard of medical care.
> Accelerate delivery of quality medical services for injured workers.
> Improve medical outcomes.
> Expedite return to work.
> Reduce unnecessary medical care and overall system costs.
> Reduce disputes resulting in timely payment to medical providers.
* American College of Occupational and Environmental Medicine and the State of Colorado guidelines (nationally recognized and evidence based).
* Comments received and new scientific literature submitted to the Board.
* Input from the Advisory Committee
In November, 2009, the Board conducted a pilot program involving 1,000 actual workers’ compensation cases. Survey of participants indicated:
* 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.
* 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 Office.
* Does not treat injured workers or perform IME’s.
phone: 1-800-781-2362 option 1
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 Board’s jurisdiction.
Standard of Care
* Medical care must be provided in a manner consistent with the Guidelines
1) Treatmentprovided 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 recommendations).
> Medical Care
> Treatment Approaches
> Time Frames
> 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 Guidelines.
* Treatment focused on restoring functional capacity to meet the patient’s 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.
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:
Eight weeks of therapy are not automatically approved. The patient must be showing continuing functional improvement which must be included in the medical documentation.
> 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 Board’s web site).
*Designate a medical professional to review requests for optional prior approval and a variance ( M.D., PA, RN or NP).
* 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 procedures.
List of Procedures Requiring Pre-Authorization:
Back and Neck
List of Procedures Requiring Pre-Authorization:
* 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 procedures
** Medical providers must use the December 1, 2010 version of the C-4AUTH form when requesting authorization
Example: For therapeutic exercise to the neck
Box #1: N for neck
Box #2: Section D for Therapeutic Procedures-Non-Operative
Box #3. 10 for Therapy-Active under Section D
Box #4. g for Therapeutic Exercise under D.10
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
* A variance request is necessary for a medical provider to provide treatment that is:
> Not consistent with the Guidelines
> Not recommended by the Guidelines
> Not addressed in the Guidelines
> Involves more, or longer periods of treatment than allowed by the Guidelines.
* Requirements for all variances:
> Provider’s opinion on medical necessity.
> The claimant agrees to the proposed medical care.
> Provider explanation of why alternatives under the Guidelines are not appropriate or sufficient.
* Variance Requirements for the Individual Claim:
> The claimant’s signs and symptoms have failed to improve with previous treatment consistent with the Guidelines.
> For frequency or duration of treatment, variances must demonstrate continued objective improvement for that treatment, and are expected to further improve with additional treatment.
> 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.
* MG-2 Doctor’s Request for Approval of a Variance and Carrier’s Response.
* MG-2.1 Continuation to form MG-2 when more than one testing or procedure is necessary which is outside of the Guidelines.
Filed by the treating medical provider with the carrier, the Board, and claimant or the claimant’s legal representative, if represented.
> Carrier must respond 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).
> 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 MG-2.
> 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.
> 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 carrier’s medical professional must review the denial unless the provider failed to provide the necessary burden of proof, the request was submitted post-treatment, or the injured worker failed to attend an IME).
> The medical provider has 8 business days to attempt to resolve the issue with the carrier. If resolved, the carrier completes the MG-2 form and sends to the various parties.
> 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.
> If both the injured worker and the carrier waive their right to a hearing, the matter is decided by a medical arbitrator, and a Notice of Decision is sent to the medical provider on form EC-71. If not, an expedited hearing is scheduled within 30 days.
> If the injured worker does not request a review timely, the Board notifies the medical provider that the denial is final on form EC-75.
In a controverted case, a carrier can approve a variance request without assuming liability of payment.
* 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.
> Carriers and self-insured employers can opt out of the optional prior approval process.
* MG-1 Doctor’s Request for Optional Prior Approval and Carrier’s Response.
* MG-1.1 Continuation to form MG-1 when requesting that more than one procedure or test is based on correct application of the guidelines.
Filed by the medical provider with the carrier and the Board. (Provider checks the Board web site to determine if the carrier is participating in the process).
> 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).
> If no response, the test or treatment is deemed approved and the Board will issue a Notice of Resolution stating the request is approved.
> 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.
> Provider receives the denial, and may attempt to informally resolve with the carrier.
> 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.
> The Medical Director’s Office reviews and responds within 8 business days with a Notice of Decision on form EC-70. The decision cannot be appealed, and the carrier cannot dispute the bill.
1) Within the criteria of the Guidelines and is based on correct application of the Guidelines
2) Based on an approved variance from the Guidelines
3) Agreed to by the payer
4) as ordered by the Board
* The recommendations of the Medical Treatment Guidelines supersede the ground rule frequency limitation for services rendered to body parts covered by the Medical Treatment Guidelines.
1) Treatment was an incorrect application of the Guidelines.
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 adjudication
> Solicited vendors for navigation software for the Workers’ Compensation Board.
> Will map diagnosis codes (ICD-9), appropriate procedure and testing codes (CPT), and Medical Fee Schedule to the correct section of the Guidelines.
> Similar products will be available for carriers and medical providers that can be tailored for their use.
> Treating physicians & chiropractors (CME and CCE credits).
> Attorneys and legal representatives (CLE credits).
> Non-medical staff such as insurance adjusters, medical provider office, billing companies, etc.
* Frequently asked questions
* The Guidelines, Regulations, Training
* Board Subject numbers 046-270, 046-346, 046-435, 046-444, 046-445, 046-449; 046-456, 046-457
* On-line capability for insurers to notify the Board for requirements specified in the regulations.
* Search capability for providers to determine the carrier contacts for the various Guidelines processes.
* 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.