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Albany In-Person Session Comments


A lot of perceptions are inaccurate. Lawyers have to provide proof of injury and they are late reporting. We want quick payment, to determine that the accident caused the injury and that the employer is not paying wages.
TPAs/Carriers , Albany

Any reaction to the comments received thus far?
Providers, Albany

Apart from some specific locations, since when are we short of providers? There is no deductible and many doctors just do not want to let go of a workers' compensation patient.
TPAs/Carriers, Albany

Application of guidelines from 1996 to now is not consistent. Surgery is better and less invasive and yet the Schedule Loss of Use awards are much higher.
TPAs/Carriers, Albany

Board has created a two-tier system of healthcare. Standards for non-workers' compensation cases differ from workers' compensation Medical Treatment Guidelines, which make it very disruptive for medical providers.
Providers, Albany

Board is relying more and more on video hearings. The dynamic is just not the same. We cannot present evidence effectively. It seems to the clients that there is no one looking out for them.
Attorneys, Albany

Board should look to make things portable. Before eCase we moved documents around and we had hearing points in every county. With today's technology it should be possible to take the hearings anywhere. Facility sharing with sites that have security already available.
Attorneys, Albany

Board takes a long time to decide threshold issues such as work related injury.
Providers, Albany

Caps should start from the DOA. Add something for acute injury vs. chronic. No one knows when someone will get to maximum medical improvement, but imposing a time limit would be an incentive.
TPAs/Carriers, Albany

Carriers require authorization for procedures that do not require prior authorization according to the Medical Treatment Guidelines. Providers' offices comply with the request for authorization to avoid lengthy conflicts.
Providers, Albany

Claimants' attorneys tell them to throw away the WA1 (work status). There is no obligation under the law for the claimant to complete the form. It is not a reason for a hearing. We have to resort to activity checks and surveillance. If they return to work for the same employer, we find out but otherwise we have no idea.
TPAsCarriers, Albany

Common reasons for late payment is (i) lack of medical evidence (ii) incorrectly filled in C4—claimants blame the insurance carriers for delay. Doctors don't find partial. They default to total unless they know the claimant is working.
TPAsCarriers, Albany

Consider the number of claims that go through Workers' Compensation Board/State Insurance Fund. The vast majority are taken care of on time.
TPAsCarriers, Albany

Despite a provider being in a Diagnostic Treatment Network, carriers still require prior authorization when it is not necessary, causing delays in treatment.
Providers, Albany

Doctors and employers should just deal with the Board who would then deal with all the other parties. The Board already knows the carrier. They should be the single source, the clearing house, and then they would have all the data and could do real data capture and analysis.
TPAs/Carriers, Albany

Does the Board monitor and collect information on frequently granted variances so that these could be incorporated into the Medical Treatment Guidelines as approved procedures?
Providers, Albany

Downstate providers are abusive of the system.
TPAs/Carriers, Albany

EMR systems must be updated every time the Board changes forms, which is very costly for providers.
Providers, Albany

Fees schedules very out of date, as much as 20 years for some. Ambulatory, emergency room, inpatient etc...
Providers, Albany

Fraud—we are second only to CA for dubious claims!
TPAs/Carriers, Albany

Historically the Board has not enforced rules regarding timely production of evidence. There are no penalties unlike those against carriers.
TPAs/Carriers, Albany

How efficient are VESID programs?
Providers, Albany

HP-1 process is too complicated and there are too many and confusing time frames associated with reporting, billing and filing HP-1s that make it difficult for providers.
Providers, Albany

If we are going to maintain our convoluted reporting process, then providers need to be paid accordingly.
Providers, Albany

Impartial specialists chosen by the Board should replace independent medical examiners.
Providers, Albany

Increase the emphasis on return to work rather than cost reduction. Access to VESID is just a check box to a claimant's attorney. It is not a serious return to work scheme.
TPAs/Carriers, Albany

It almost seems that the Board is understaffed.
Attorneys, Albany

It is surprising that there are not more incidents because we are dealing with people who are struggling to feed their families, who do not know what is going to happen to them.
Attorneys, Albany

Judges cannot fully appreciate the medical complexity, terminology and procedures to accurately render decisions.
Providers, Albany

Lack of staffing is a grave concern. It is quicker to send a fax saying we will be late than to call in. When I do case reviews, I spend two hours out of every four on hold with WCB.
Attorneys, Albany

Large problem with independent medical exams. "I" should stand for "Independent"; however, it more accurately stands for "Insurance". Numerous accounts of independent medical exams that lasted only five minutes with extensive reports written that do not reflect what happened during the exam.
Providers, Albany

Lessen the provider's burden of form completion. Have a standard submission for workers' compensation like that of commercial and private health.
Providers, Albany

Loss costs are so high; premiums are astronomical. Medical costs are higher and higher due to new services and the cost of care.
TPAs/Carriers, Albany

Make video taping mandatory for all independent medical exams so a record of what transpired during the exam is available.
Providers, Albany

Many providers do not want to deal with the system and the forms. It’s hard for doctors to know even which form they should be filling in.
TPAs/Carriers, Albany

Medical billing company finds that temporary impairment field often not completed, which delays the submission of the report and bill. Not sure why providers cannot complete these questions.
Providers, Albany

Medical Treatment Guidelines were created by a limited representation of specialties. There was no orthopedic surgeon on the MTG Advisory Committee that created the Guidelines.
Providers, Albany

Medicare is not a high payer, but it is a simple administrative reporting burden is easy and many providers participate.
Providers, Albany

Modernization = one point of contact = Workers' Compensation Board.
TPAs/Carriers, Albany

Need more mental health resources. Seeing may consequential depression instances and cannot find psychiatrists to treat claimants. Why can't the Board do a target outreach to recruit psychiatrists?
Providers, Albany

Need to focus on getting claimants back to work.
Providers, Albany

No insurance companies push return to work.
Providers, Albany

Not the subject of this engagement, but the Department of Labor, Federal WC is a "nightmare".
Providers, Albany

Occupational health clinic had no payment issues.
Providers, Albany.

Occupational health clinics seeing many more workers' compensation patients because of the lack of primary care physicians.
Providers, Albany

Other jurisdictions do not require the claimant to show proof. Carrier shows proof of non-injury or lack of causation.
TPAs/Carriers, Albany

Other jurisdictions require electronic filing.
TPAs/Carriers, Albany

Out of state bill review companies do not know the NYS WC treatment and billing protocols which cause payment issues.
Providers, Albany

Physician stated that there is a learning curve. Two years ago had problems with the Medical Treatment Guidelines and forms. Now they know how to do it.
Providers, Albany

PPD claims are a real problem.
TPAs/Carriers, Albany

Primary providers often do not know how to complete these questions.
Providers, Albany

Problems finding primary physicians to clear a patient for surgery.
Providers, Albany

Providers complain that they send in the bill—the Board has it and they just assume that the carrier has it even though they don't.
TPAs/Carriers, Albany

Providers have not educated themselves on the Medical Treatment Guidelines.
TPAs/Carriers, Albany

Providers who take on patients who have treated with other doctors must reach out to carriers to determine what previous course of treatment were done to ensure that they treat within the Medical Treatment Guidelines. Need a better way for providers to access this information.
Providers, Albany

Put the Workers' Compensation Board case number on all forms! We hear there are currently more than one million forms unassembled and unassigned.
TPAs/Carriers, Albany

Right now no one knows where the delays are. Provider? Carrier? The Board?
TPAs/Carriers, Albany

Rocket docket is great. We do not controvert as many claims as we used to.
TPAs/Carriers, Albany

Schedule Loss of Use awards are litigated a lot more now due to the size of them. The cost of them has gone up exponentially as has the number of them.
TPAs/Carriers, Albany

Schedule Loss of Use has been in place for several years but now you have the rate increase and settlements are greater than Section 32s!
TPAs/Carriers, Albany

Should automatically refer to independent medical exam for loss of use >25% and create a fee schedule for independent medical examiners. Vocational rehabilitation does not get the focus it should.
TPAs/Carriers, Albany

Society of Orthopedic Surgeons conducted a study of MG-2 variance requests by orthopedic surgeons and found that 80% were granted. Of the 20% not granted, 905 were ultimately approved by the Board.
Providers, Albany

Something needs to be done about independent medical exam mills.
Providers, Albany

State doctors need to create a uniform set of decisions as to impairment. Recently the percentage loss of use has increased significantly.
TPAs/Carriers, Albany

Take out surgery procedures from 1996 guidelines and focus on range of motion, use and loss instead.
TPAs/Carriers, Albany

Terrific that the Board has decided to do this top to bottom analysis.
Providers, Albany

The balance has shifted so that employees and employers are serving the Board and not the other way around. WISKs are one of the best things the Board has done but I have a problem with the permanency parts. The Board has taken on the role of the carrier.
Attornyes, Albany

The Board should issue an insurance card to claimants that they must present when seeking treatment not unlike a private health insurance card.
Providers, Albany

The centralized customer service system means that I may be sitting in Albany but I am talking to someone in Rochester who does not know the local information. They refer me to someone else who turns out to be downstate.
TPAs/Carriers, Albany

The creation of Diagnostic Treatment Networks who offer deep discounts to medical providers has kept good providers out and attracted mills.
Providers, Albany

The delays are a problem for us and other insurers having to calculate reserves against future payments.
TPAs/Carriers, Albany

The new fee schedules may attract a better quality of provider.
TPAs/Carriers, Albany

The variance process is extremely complex and this causes delays in treatment. The Board has made it so technical to get treatment outside the guidelines.
TPAs/Carriers, Albany

There are delays in capping cases. Judges and/or maybe the claimants bar are resistant. Many cases are being resolved outside the hearing process. The new PPD parts are too new to assess whether they will address the delays.
TPAs/Carriers, Albany

There is a big motivation to pursue Schedule Loss of Use awards, which is a huge cost driver.
TPAs/Carriers, Albany

There is a lot of incentive to stay out of work.
TPAs/Carriers, Albany

There needs to be a partial rate. Instead of using $800, use $600 or $400.
TPAs/Carriers, Albany

Variances are going to hearings rather than the medical director. There is a lack of understanding of the process and internal policies of the provider (in terms of authorization, etc.) do not always align with the guidelines.
TPAs/Carriers, Albany

VESID changed to ACCESS. It now takes a long time for a referral to a Job Coach, as much as six months.
Providers, Albany

We are developing into a system that is like the criminal court system. We cannot afford to adopt a cookie cutter justice approach to workers' compensation cases. If efficiency is detracting from meeting the mission then something is wrong.
Attorneys, Albany

We cannot get classification since the caps. It used to be that classification guaranteed lifetime payment, but now there is no incentive to classify.
TPAs/Carriers, Albany

We have nothing but the utmost respect for the Workers' Compensation Board.
TPAs/Carriers, Albany

We settle a lot of cases through section 32s. Employer and employee may not be happy but that may not be inappropriate.
TPAs/Carriers, Albany

We want to be able to pay with ETF or a debit card instead of cutting checks. Many claimants don't have accounts and are paying a check cashing service 20% fees in order to get their payments. Other payment methods should be the norm in this day and age.
TPAs/Carriers, Albany

What are some of the themes we have heard thus far?
Providers, Albany

Why don't we use the American Medical Association (AMA) Guidelines?
Providers, Albany

Why have there been so many changes in such a short period of time? Medical Treatment Guidelines, impairment, eClaims. Policy holders are not aware of how the system works and none of us can keep up with the changes.
TPAs/Carriers, Albany