As published in The Bulletin (February/March 2016 issue)
Journal of the Monroe County Medical Society
A wise person once said that “The only people who like change are babies with wet diapers.” Some changes are coming in 2016 for health care providers who treat injured workers in the New York Workers’ Compensation [“WC”] system. Other changes have been proposed. Here is what you need to know.
CHANGES YOU COULD SEE
Rates of Payment
The New York Workers’ Compensation Board [“WCB”] has not adjusted rates of payment for health care services for more than a decade. According to the sponsor of Assembly Bill A03158 (Matthew Titone, D–Staten Island), the rate paid for many health care services in the WC system is the “lowest or near the lowest” in the United States.
If enacted, this bill would require the WCB to prepare and establish a rate schedule for health care services every two years. Earlier this year, this bill was referred to the Assembly Labor Committee for consideration.
Governor’s Proposed Budget
Governor Cuomo recently proposed his $145 billion Executive Budget for 2016-17–http://www.budget.ny.gov/pubs/executive/eBudget1617/fy1617artVIIbills/PPGGArticleVII.pdf
As part of that proposal, he seeks the following changes regarding the provision of health care services in the WC system:
Broaden Those Authorized to Treat Injured Workers from “physicians” to “providers.” Providers include acupuncturists, chiropractors, nurse practitioners, occupational therapists, physical therapists, physicians, physician’s assistants, podiatrists, psychologists and licensed clinical social workers.
Limit the Role of Some of These Providers. Physical therapists, occupational therapists and acupuncturists are NOT permitted to opine on causal relationship or degree of disability. Nor can they conduct independent medical examinations.
Create an “Authorization Agreement” between Providers and the WCB that permit the providers to render treatment. The WCB would be authorized to remove any provider who: (1) breaches the agreement; or (2) “has failed to render competent, professional or quality medical care and treatment.”
CHANGES YOU WILL SEE
The WCB has proposed regulation changes that, when adopted, will change significantly how providers secure authorization for certain types of treatment for injured workers. To appreciate these proposed changes, recalling some history will help.
MTG were Implemented in 2010
In December of 2010, the WCB implemented Medical Treatment Guidelines [“MTG”] that “fundamentally changed the delivery of health care to injured workers.” MTG have become the standard of care for treating injured workers who have work-related injuries affecting the neck, middle and low back, shoulder and knee. MTG also is the standard of care for injured workers who have carpal tunnel syndrome or non-acute pain.
The MTG are found at: http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/MTGOverview.jsp
MTG Authorization Process
As a general rule, pre-authorization is NOT required when MTG applies and the treatment rendered is consistent with it.
Pre-authorization (by completing and submitting form C-4 AUTH) is required for specific treatments which include: (1) lumbar fusion; (2) artificial disk replacement; (3) vertebroplasty; (4) kyphoplasty; (5) electrical bone growth stimulators; (6) spinal cord stimulators; (7) osteochondral autograft; (8) autologus chrondocyte implantation; (9) meniscal allograft transplantation and (10) knee arthroplasty (total or partial knee joint replacement).
A variance (by completing and submitting form MG-2) is required when the treatment sought is inconsistent with the MTG.
Medical providers may request prior approval for anticipated treatment (by completing and submitting from MG-1), however, the “payor” (insurance company or the self-insured employer) is NOT required to respond. In our experience, most MG-1s get NO response at all.
Frustration with the MTG Authorization Process
The current process is fraught with paperwork and numerous opportunities for delay. Providers have to select and complete the correct form. They sometimes fail to do so. They also sometimes fail to provide information that is legible or sufficient to justify the treatment they are seeking.
The provider mails or faxes the completed form to the payor and the WCB. Neither typically acts quickly. Payors are required to designate contacts to assist providers with variance approvals (MG-2), optional prior approvals (MG-1) and pre-authorizations (C-4 AUTH), however, this has been a well kept secret.
Some payors will (with or without a reasonable basis) request more information from the provider. Providers are very busy and often cannot respond to such requests as soon as they would like. The WCB will reject some forms submitted by providers for technical reasons (e.g., form not signed by a medical doctor). Phone calls made to “short cut” the process go unreturned.
All this takes far too long. The length of this process can compromise how quickly the injured worker heals and returns to work. This is bad for the injured worker, bad for the provider and bad for the payor.
The Medical Portal
By the end of 2016, the WCB expects to implement a web-based Medical Portal. This portal will enable users to submit medical information electronically. We recently participated in a webinar which demonstrated the Medical Portal.
To see a demo of the Medical Portal, and to get more information, visit http://www.wcb.ny.gov/content/ebiz/medicalportal/overview.jsp
The first phase of the Medical Portal will allow providers to submit the salient forms (C-4 AUTH, MG-1 & MG-2) electronically. The system uses an interactive process that will help even inexperienced providers determine the proper path based upon the answers they provide to questions posed by the Medical Portal.
For example, a provider who seeks pre-authorization for a laminectomy will NOT be permitted to submit a C-4 AUTH because that is not one of the specific treatments that can support a C-4 AUTH. In other words, the system should prevent providers from completing the wrong form. Moreover, because the form is completed electronically, there should be no “legibility” issues.
The system also is designed to prevent providers from failing to submit information necessary to justify the treatment they are seeking. To illustrate, providers will be required to use the Medical Portal to attach the relevant medical evidence to support their request.
Providers will be able to check the status of their authorization request in real time. Providers can communicate with payors electronically through the Medical Portal, avoiding missed phone calls. Payor deadlines to act will be set in the Medical Portal. Providers will be notified when the payor takes action.
According to the WCB, the Medical Portal is intended “to make medical treatment authorization requests easier; bringing significant improvements to a complicated and often times confusing process.” If it is successful, the streamlined authorization process will help injured workers recover faster and will reduce the administrative burden on providers, payors and the WCB. Moreover, the streamlined authorization should be greener, have fewer errors and help us collect better data on which to evaluate our WC system.
Will the Medical Portal be successful? Only time will tell. The WCB is looking for providers that are willing to “beta test” the Medical Portal. You can express interest in doing so by sending an e-mail to email@example.com.
You are also invited to contact the WCB’s Medical Director about MTG and related issues by phone (1-800-781-2362) or by e-mail (WCBMedicalDirectorsOffice@wcb.ny.gov). We look forward to working with you to serve injured workers.
Steven V. Modica, Esq. is the principal owner of the Modica Law Firm. The firm represents injured workers in Workers’ Compensation, personal injury and disability benefit cases. The firm also represents employers, employees and unions in employment disputes.