State of New York Workers’
Compensation Board ; Bureau
of Health Management
Board Meeting
February 15, 2011
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Medical Treatment Guidelines
 Administrative Overview
 Overview of the history, background and goals of the
Guidelines and the Board’s implementation process.
 Medical Director’s Office
 General principles
 Procedures requiring pre-authorization
 Variance process
 Optional prior approval process
 Payment of medical bills/objections
 Navigation software
 MTG resources/training
 The future of MTG
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Medical Treatment Guidelines
 History
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2007; Legislation was adopted to reform NY Workers’ Compensation Laws.
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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 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 16th, 2010.
November 3, 2010; Notice of adoption posted on NY State Register
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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.
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Medical Treatment Guidelines
 The Guidelines apply only to treatment of injuries
to the:
> Low & Mid back
> Neck
> Shoulder
> Knee
 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.
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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.
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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
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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
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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.
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Medical Treatment Guidelines
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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: 1-800-781-2362 option 1
WCBMedicalDirectorsOffice@wcb.state.ny.us
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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.
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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).
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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.
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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.
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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:
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- Principle 3: Positive Patient Response.
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- 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.
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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).
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Medical Treatment Guidelines
 Pre-Authorization
* Any treatment that is consistent with the
Medical Treatment Guidelines is preapproved 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.
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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
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Medical Treatment Guidelines
List of Procedures Requiring Pre-Authorization:
Knee
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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
** Medical providers must use the December 1, 2010 version of
the C-4AUTH form when requesting authorization
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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 ProceduresNon-Operative
Box #3. 10 for Therapy-Active under Section D
Box #4. g for Therapeutic Exercise under D.10
-
N
D
10
g
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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
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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.
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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.
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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.
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Medical Treatment Guidelines
 Variance Request Forms
* 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.
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Medical Treatment Guidelines
 Carrier Response to the Variance Request
> 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.
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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
necessary burden of proof, the request was submitted posttreatment, 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.
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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, and a
Notice of Decision is sent to the medical provider on form EC71. 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.
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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.
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Medical Treatment Guidelines
 Optional Prior Approval Forms
* 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).
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Medical Treatment Guidelines
 Optional Prior Approval; Carrier Response
> 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.
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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 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.
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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
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Medical Treatment Guidelines
 Fee Schedule Ground Rules
* 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.
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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
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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.
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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.
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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, 046435, 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.
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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.
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