A medical guideline goes by various names, such as clinical guidelines, standard treatment guidelines, or clinical practice guidelines. It serves as a framework for determining an appropriate diagnosis, management plan, and treatment approach tailored to specific medical specialties. Additionally, medical guidelines often incorporate concise consensus statements on best practices in healthcare. Healthcare professionals need to acquaint themselves with the medical standards of their profession and decide whether to follow the recommended treatment course.
The purpose of a Medical Treatment Guideline (MTG) is to establish evidence-based standards of care and best practices in medical treatment for work-related injuries. Physicians can ensure that the insurance company covers medical care for injuries or illnesses without requiring prior approval.
However, if a physician believes that a different treatment is more suitable than the recommended guidelines, they have the option to request a deviation. To do so, the physician must demonstrate that the proposed treatment is both reasonable and medically necessary. The request for variation must be made before the physician initiates the treatment. Having an experienced Workers’ Compensation attorney negotiate with the medical provider is advisable in such situations.
Workers’ Compensation legislation has sanctioned the expansion of authorized medical providers for treating injured workers in New York. This legal update enables a broader range of healthcare professionals to attend to a larger number of injured workers.
Effective January 1, 2020, licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, and occupational and physical therapists may now seek board authorization to become providers. Any healthcare provider treating injured workers under Workers’ Compensation must obtain board authorization, prohibiting physicians from treating and billing using their physician authorization number.
The Workers’ Compensation Board website facilitates a straightforward online application and renewal process for obtaining authorization. Moreover, healthcare providers and payers can enroll in the Board’s Medical Portal, enabling the submission of medical information for online review.
The Board has taken proactive measures to enhance the Workers’ Compensation system for providers, with the goal of encouraging broader participation. Additionally, the Board has introduced new fee schedules, featuring increased reimbursement rates and additional raises for specific specialty provider groups.
The Board has made updates to several fee schedules, including inpatient and outpatient compensation for injured workers, Enhanced Ambulatory Patient Group (EAG) fee schedules, Podiatry fee schedule, Dental fee schedule, Private Psychiatric Hospital fee schedule, and Durable Medical Equipment fee schedule. This includes payable fees for out-of-state treatment, and detailed information for each fee schedule.
Ground Rule 17 has been implemented to enhance provider reimbursement, specifically targeting an increase in the number of board-authorized providers in primary care medicine, such as family medicine, general practice, and internal medicine specialties. Additionally, a specific modifier, 1D, has been introduced to provide a 20% reimbursement increase for rating codes and services under Rule 18.
For behavioral health providers, an enhanced reimbursement modifier, 1B, offers a 20% increase for providers with board-assigned rating codes for designated services. Designated providers should use the appropriate modifier if not yet paid by filing an HP-1 form and assigning delegates. The Board can assist in drafting prior authorization requests (PARs), review and submission of escalations to level two medication PARs, and preparation of escalations to level three for review by the medical director’s office. The Board can also assist in responding to information requests, drafting and submitting decisions on unpaid medical bills, or completing Form HP.
The Board’s formulary contains a preferred medication list that can be prescribed without requiring prior approval. However, requesting a newer medication refill for a patient’s current medication at a lower strength necessitates a request for non-formulary drugs through the Medical Portal process.
Legislatively mandated medical treatment guidelines (MTGs) have changed healthcare delivery for injured workers, introducing four evidence-based guidelines for neck, back, and shoulder injury treatment. Additionally, MTGs for the ankle and foot, elbow, hand, wrist, and forearm (including carpal tunnel syndrome), hip, growth disorders, occupational interstitial lung disease, and occupational or work-related asthma injuries have been incorporated into the guidelines.
The Medical Treatment Guidelines (MTGs) in New York underwent updates in September 2021, encompassing mid and lower back, neck, knee, and shoulder injuries, as well as non-acute pain. Additionally, the Board incorporated MTGs for post-traumatic stress disorder (PTSD), acute stress disorder, work-related depression, and depressive disorders, formerly known as major depressive disorder.
Payers have the option to electronically transmit Explanation of Benefits (EOBs) or Explanation of Reviews (EORs) to their XML submission partner for the adjudication of electronic CMS-1500, acknowledging medical bills within seven business days. However, a payer may reject an electronic bill from the designated XML submission partner for reasons such as a mandatory field left blank or the insurer declining coverage for the employer. Any rejection must occur within seven business days of the initial transmission date by the provider’s XML submission partner or clearinghouse.
Payers are obligated to identify all legal and valuation objections for medical bill payment and submit them with EOB/EOR payers within 45 calendar days of receiving the medical bill, whether in paper or digital format. Additionally, the payer must file objections with the Board.
While providers are encouraged to use an XML submission partner for CMS-1500 submissions, it is not mandatory when the use of current medical billing reports, such as the physician’s initial report, begins.
The provider must include a narrative medical report of the patient’s temporary impairment percentage and work status related to the injury at the top of the CMS-1500 form. Payers must utilize Form C-8.1B and Form C-8.4 with applicable C arcs for medical bill objections. Electronic EOBs provided to healthcare providers must identify the same CRC (Claim Reference Code) as specified on Form C-8.1B or Form C-8.4.
When using the medical narrative template, providers should attach a narrative report including examination findings, the history of the injury or illness, objective findings based on clinical evaluation, and diagnosis. If not using the template, the provider should include patient assessment, plan of care, and the provider’s medical narrative report.
For additional information, consult your state’s Workers’ Compensation Board website or seek advice from a Workers’ Compensation attorney.
