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

2 Topics Medical Treatment Guidelines Overview of the history, background and goals of the Guidelines and the Board’s implementation process. Medical Director’s 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

3 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, November 30, 2009; Pilot project commenced to test the Draft Medical Treatment Guidelines processes. 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 16 th, November 3, 2010; Notice of adoption posted on NY State Register

4 Medical Treatment Guidelines Effective Date > 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.

5 Medical Treatment Guidelines Mid &Low Back Injury Knee Injury Neck Injury Shoulder Injury The Medical Treatment Guidelines apply to treatment of these injuries only

6 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.

7 Medical Treatment Guidelines Goals > 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.

8 Medical Treatment Guidelines Development of the Guidelines * 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

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

10 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 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.

11 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 Office. * Does not treat injured workers or perform IME’s. phone:

12 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 recommendations).

13 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 Board’s jurisdiction.

14 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 coverage) Uniformed Firefighters of: * Auburn (prior to 7/1/07 and after 6/30/08) Buffalo, Elmira, Rochester, Rome, Syracuse, and Utica.

15 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 military. Railroad employees St. Lawrence Seaway employees

16 Medical Treatment Guidelines General Guideline Principles > 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. Two categories will be discussed; Medical Care & Treatment Approaches

17 Medical Treatment Guidelines General Principles-Medical Care * 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. * Provider must implement educational strategies which provide reassuring information to the patient (ie: self-management of symptoms and future injury prevention).

18 Medical Treatment Guidelines EXAMPLE: 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.

19 Medical Treatment Guidelines Re-Evaluations/Positive Patient Response > 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.

20 Medical Treatment Guidelines Positive Patient Response > Positive patient response is measured by functional improvement that can be objectively measured. > 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 quantified.

21 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 program.

22 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.

23 Medical Treatment Guidelines Insurance Carrier Responsibilities > 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).

24 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 procedures.

25 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

26 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 replacement) * 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 ** Use the December 1, 2010 version of the C-4AUTH form when requesting authorization (Required for the MTG).

27 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, MRI’s 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

28 Pre-Authorization For Medical Care Denial of the Authorization Request > 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

29 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 Procedures- Non-Operative Box #3. 10 for Therapy-Active under Section D Box #4. g for Therapeutic Exercise under D.10 ND10g -

30 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

31 Medical Treatment Guidelines Variance * 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.

32 Medical Treatment 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.

33 Medical Treatment Guidelines * 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.

34 Medical Treatment Guidelines Variance Forms * MG-2 Doctor’s Request for Approval of a Variance and Carrier’s Response. Filed by the provider with the carrier, the Board, and claimant or the claimant’s 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.

35 Medical Treatment Guidelines Variance Process > Provider determines if treatment necessary is outside the Guidelines and requests a variance on form MG-2 and submits it to the appropriate parties. > 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). > 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.

36 Medical Treatment Guidelines Variance Process; Carrier Denial > 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 needed burden of proof, the request was submitted post- treatment, or the injured worker failed to attend an IME). > 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.

37 Medical Treatment Guidelines Variance Process; Carrier Denial > 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. If not, an expedited hearing is scheduled. In a controverted case, a carrier can approve a variance request without assuming liability of payment.

38 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. > Carriers and self-insured employers can opt out of the optional prior approval process.

39 Medical Treatment Guidelines Optional Prior Approval Forms * MG-1 Doctor’s Request for Optional Prior Approval and Carrier’s 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 guidelines.

40 Medical Treatment Guidelines Optional Prior Approval Process > 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). > 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.

41 Medical Treatment Guidelines Optional Prior Approval Process; Carrier Denial > 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 arbitrator reviews and responds within 8 business days. Decision cannot be appealed, and carrier cannot dispute the bill.

42 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 Guidelines 3) Agreed to by the payer OR 4) as ordered by the Board

43 Medical Treatment Guidelines Carrier’s post-treatment objection to a bill due to Guideline Issues- 3 Reasons 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

44 Medical Treatment Guidelines  Navigation Software > 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.

45 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.

46 Medical Treatment Guidelines Free Web-based Training > 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.

47 Medical Treatment Guidelines Free Web-based Training * > 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 option # 2

48 Medical Treatment Guidelines Web Site Changes; New Section on the Guidelines * Frequently asked questions * The Guidelines, Regulations, Training * Board Subject numbers , , , , , ; , * Search capability for providers to determine the carrier contacts for the various Guidelines processes.

49 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: ; Option 1

50 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. MEDICAL PROVIDER INSURANCE CARRIER WORKERS’ COMP. BOARD Payment

51 Insurance Carrier Lack of Response to the Medical Bill 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 Workers’ Comp. Board HP-1 Form

52 Filing for an Administrative Award * No legal issues are present in the case. * Provider’s original signature. * One billing cycle per HP-1. * Include a copy of the original bill submitted (supporting narratives or office notes not required). * 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 bill.

53 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. MEDICAL PROVIDER INSURANCE CARRIER WORKERS’ COMP. BOARD Arbitration Issue Raised C-8.4 form Request Arbitration HP-1

54 Arbitration/Valuation Issues Amount of the medical bill is: * Not in accordance with the fee schedule * Not properly pro rated or apportioned between providers * Not in accordance with ground rule limitation * Not correct for the particular CPT code (s)

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

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

57 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.

58 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 ).

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

60 Other Recent Regulatory Changes Carrier Notice to the Health Care Provider of a Carrier’s 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, * Sent to the medical provider, the Board, and the claimant’s attorney (or the claimant if not represented). * 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 schedule.

61 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

62 Form Changes; December 1, 2010 C 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)

63 Boards’ On - line Services for Providers Providers can complete and submit C - 4, C - 4.2, and C 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

64 Resources For Medical Providers > Bureau of Health Management/Health Provider Administration (800) > Board Customer Service (877) > Board Fax Number (877) > Rochester District Office (866)

65 This presentation is intended to provide New York medical providers with general information regarding the State’s 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.