When you are injured on the job in New York, your employer’s workers’ compensation insurance policy usually covers the cost of your medical treatment. Since 2010, however, the Workers’ Compensation Board of New York has also been in control of the type of treatment most injured employees receive. To maintain this control over treatment, the Workers’ Compensation Board requires all injured employees to receive care in accordance with the Board’s Medical Treatment Guidelines.
What Are the Medical Treatment Guidelines?
The WCB characterizes the Medical Treatment Guidelines as the “standard of care” for injured workers in the state of New York. As of December 1, 2010, adherence to the Medical Treatment Guidelines became mandatory in the treatment of any injury the guidelines cover, with the exception of treatment received in emergency situations. They apply regardless of the health insurance payer type. The guidelines have also been updated several times since they were initially published. Some of these revisions were minor, while others changed care recommendations significantly.
How Were the Medical Treatment Guidelines Developed?
New York’s Medical Treatment Guidelines were developed using evidence-based medicine. This means that the guidelines are based on the latest scientific data available, as well as the input of experienced doctors around the country. They are attempting to lower the alarming statistics regarding injuries.
Why Were the New York Medical Treatment Guidelines Developed?
The WCB adopted the Medical Treatment Guidelines for several different reasons. One of their state reasons for developing these guidelines was to improve the quality of treatment injured workers receive in order to expedite their return to work and improve the overall outcome of care. These guidelines also exist to reduce the number of disputes that occur between payers and medical treatment providers by providing clear instructions for recommended treatment. Finally, the WCB implemented the Medical Treatment Guidelines in hopes of reducing the expenses associated with the workers’ compensation system.
What Injuries are Covered?
The Medical Treatment Guidelines cover the injuries that occur most frequently on the job in New York. Injuries covered by these guidelines include neck injuries, back injuries, shoulder injuries, knee injuries, chronic pain and carpal tunnel syndrome.
The guidelines cover all aspects of treating any given injury, from the initial diagnosis to the number of follow-up visits the employee can schedule. Under these guidelines, many tests and treatments can be administered without prior approval from the insurer, regardless of their cost. However, certain procedures must be approved in advance. These procedures include knee joint replacement, artificial disk replacement, lumbar fusion, meniscal allograft transplantation, steochondral autograft, Spinal Cord Stimulators, autologus chrondocyte implantation, electrical bone growth stimulators, kyphoplasty and vertebroplasty.
Pre-authorization for treatment may also be required for treatment when an injury is not covered by New York’s Medical Treatment Guidelines. In such cases, physicians must typically request authorization when a procedure will cost more than $1,000.
Can Doctors Deviate from the Guidelines?
Healthcare providers in New York are expected to adhere to the Medical Treatment Guidelines when treating any injury covered by workers’ compensation. However, in some cases, a doctor may believe that the treatment or testing recommended in the guidelines is not the best course of action for a specific patient. If this occurs, the doctor may be able to deviate from the guidelines if he or she requests approval from the payer. The payer may grant approval for the treatment change if the doctor is able to explain why the change is necessary.
Recent Changes to New York’s Medical Treatment Guidelines
The Workers’ Compensation Board updates the Medical Treatment Guidelines based on new information in the medical field and the recommendations of doctors. Unfortunately, these updates are not always beneficial to workers’ compensation claimants. Most recently, the WCB changed some of the guidelines used in the treatment of non-acute, long-term pain. These new rules alter the guidelines physicians must use when prescribing pain medications.
The goal of these changes was to reduce the use of habit-forming medications, such as narcotics, in the management of chronic pain. The new guidelines also encourage more interaction between doctors and patients who have been prescribed habit-forming medications. For example, under these new guidelines, patients receiving opioid prescriptions must participate in ongoing drug tests and psychological evaluations. Patients must also be educated with regard to the dangers associated with any pain medications they are prescribed.
If you are involved in a workers’ compensation case in New York, you may benefit from speaking with an attorney. This is especially important if your claim has been disputed or denied. Please contact Paul Giannetti, Attorney at Law, for guidance.
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