The Role of Medical Providers in Workers’ Compensation

Healthcare professionals play a crucial role in the New York State Workers’ Compensation system, especially in the process of becoming board-authorized providers. Workers’ Compensation is a type of insurance designed to cover work-related accidents, injuries, and illnesses, providing benefits such as medical treatment expenses and wage replacement. This coverage is essential for both employers and employees, with the responsibility for securing insurance falling on employers.

Workers’ Compensation ensures that employees are entitled to benefits without having to contribute to the cost of coverage. Employers must report incidents to the Workers’ Compensation Board, and employees have up to two years to file a claim, excluding World Trade Center-related claims. Claims become payable once the employer or insurance carrier acknowledges the work-related nature of the illness or injury. Disputes, however, may lead to a decision by a Workers’ Compensation law judge.

Who needs Workers’ Compensation insurance?

All profit businesses with employees, as deemed by the Workers’ Compensation Board, must have insurance coverage. This includes various categories of workers such as day laborers, volunteers, part-time workers, family members, and subcontractors. Nonprofit organizations also require coverage for specific employees, particularly those working in domestic roles for at least 40 hours weekly, including hours spent sleeping within the home.

The New York State Workers’ Compensation Board oversees the maintenance of mandatory insurance by employers, receives claim documents, and conducts dispute hearings when necessary. Board-authorized providers, including physicians, chiropractors, podiatrists, and psychologists, play a vital role in administering essential medical care, documenting treatments, and providing additional details, undergoing specific training.

Recent changes in the law now allow licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, and occupational and physical therapists to obtain authorization, aiming to modernize and enhance Workers’ Compensation, healthcare options, and patient accessibility. This is anticipated to bring a significant influx of new providers into the system.

Providers play a critical role in commenting on various aspects of a claim, including the causal relationship, diagnosis, treatment, and disability evaluation. They use the CMS-1500 form and must attach a medical narrative report to it. XML form submission registration on the Board’s website is a prerequisite for submitting CMS-1500 and narrative reports.

It’s important to note that medical providers cannot bill patients directly, and failure to comply may result in revocation of Board authorization. Instead, providers should submit medical bills to the insurance carrier or use a self-insured employer form directly. The submission timeline is crucial, with a 90-day limit for most providers and 120 days for hospitals.

Patients may be asked to sign a form acknowledging responsibility for medical costs if the Board rejects compensation. All submitted documents become evidence in the Workers’ Compensation case, including testimony and depositions.

Providers may be called upon to provide testimony and depositions within the Workers’ Compensation system, and reimbursement for services follows the medical fee schedules, which are specific to each authorized provider and service type. For licensed clinical social workers and psychiatric nurse practitioners, presenting medical evidence of the stressful experience is crucial when treating patients with work-related mental stress claims.

Who might go through stress related to their work?

Professionals facing exceptional work-related stress encompass first responders like police officers, firefighters, EMTs, paramedics, certified emergency medical providers, emergency dispatchers, and similar roles.

However, when it comes to claiming Workers’ Compensation benefits for mental stress, it’s not as straightforward. The employee doesn’t qualify for such benefits. Instead, consequential psychological injury may be applicable if the stress is a result of a legitimate personnel decision involving the employer’s disciplinary actions, work evaluations, job transfers, or terminations.

Consequential psychological injuries could manifest as conditions like depression or post-traumatic stress disorder (PTSD) triggered by an initial injury or illness. To establish a case, the provider needs to demonstrate that the natural consequences of the initial physical injury led to a psychological injury.

For instance, if an employee is unable to work for an extended period due to a work-related back injury causing depression, it must be shown that the depression resulted directly from the back injury, impacting daily life activities and work responsibilities. The recent provider authorization process mandates medical professionals to seek approval through the Board’s Medical Portal on their website.

The provider’s journey involves registering, requesting access to the Medical Portal, and obtaining user credentials as part of the authorization process. Completion of all necessary training is a prerequisite before submitting Board authorization, and the online application must be done in a single session.

Before initiating the authorization application, the provider needs to have the following information ready:

  • Full name (first, middle, and last)
  • Date of birth
  • Mailing address
  • Mailing practice address
  • New York state license number
  • Details of the authorized and registered supervising physician, including name, authorization, and license number
  • Copies of relevant Board certifications, if applicable (e.g., American Board of Medical Specialties, American Osteopathic Association, or National Certification Commission for Acupuncture and Oriental Medicine)
  • Disciplinary information
  • Workers’ Compensation Board prior authorization number, if applicable
  • Curriculum vitae or resume
  • For physician assistants: national provider identifier, email address, and a list of languages spoken

Treatment of Workers’ Compensation claimants is not permitted until the application receives approval and the Board authorizes it. Physician assistants need to submit their authorization application to the county’s medical society where the physician’s primary office is located, the specific county medical society, or the New York State Osteopathic Medical Association.

In the case of osteopathic physicians, the Workers’ Compensation Board considers the county medical society’s recommendation when granting authorization approval.

For further details, you can refer to your state’s Workers’ Compensation Board website or consult with a Workers’ Compensation attorney.


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