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Glossary of WCB Terms

Here's What We are Hearing


9/20/2013

  1. The number of claims indexed or assembled by the Board declined from 174,802 in 2001 to 123, 245 in 2011. Although there is a long-term trend in declining frequency of claims, it is unlikely that this accounts for the extraordinary decline in indexed/assembled claims. It is probable that there is a significant lack of information and access to benefits by low-wage workers, and that the decline in claims is partially representative of a loss of benefits by this population.
  2. There are significant obstacles to claim filing. These obstacles disproportionately impact the group of workers that is most likely to require access to the system. The cumbersome C-3 form and the hypertechnical requirements for case assembly/indexing are significant factors. The lack of direct outreach by the state agency to injured workers, as well as the absence of a requirement that employers distribute information are also relevant.
  3. Communication about worker rights in the system is ineffective. The use of non-hearing determinations is problematic as they cannot and do not effectively provide information to injured workers due to language, literacy and other obstacles.
  4. There is inadequate access to medical care in the workers' compensation system. From 2004 to date the Board has removed 330 doctors from its provider lists (through suspension and voluntary resignation). 306 of the 330 have been removed since 2007. There is a clear relationship between the loss of providers and the mushrooming of the number, length, and content of medical reporting forms. The Board's web site currently lists 37 forms for use by health care providers, virtually all of which are multi-page forms.
  5. Benefits remain inadequate despite the increase in the statutory maximum rate. From 1992 -2006 the minimum rate of $40 was 10% of the maximum rate of $400. The increase of the minimum rate to $100 in 2007 made it 20% of the maximum rate of $500. However by 2012 it had declined to 12% of the maximum rate of $792.07 due to the failure to index the minimum rate. The 2013 increase to $150 has restored the minimum rate to 18% of the maximum rate (still short of its 2007 percentage). However, it will inevitably sink back into irrelevance until it is indexed to the maximum rate.
  6. The standard for temporary disability must be revisited. The general principle of total disability is that a worker must be unemployable. However, in cases of temporary disability a worker's hypothetical ability to perform other work is largely irrelevant. As a matter of practicality, it is unreasonable to expect a temporarily disabled worker to seek out other employment or to engage in vocational retraining when that worker has a reasonable expectation of returning to his or her previously employment (and employer) and in fact may be prohibited from seeking other employment due to a collective bargaining agreement, employer policy, or employment contract. A temporarily disabled worker should be paid for total disability as long as they are unable to return to their former employment or any modified duty position reasonably offered by the employer.
  7. Data must be collected and oversight brought to the use of so-called "independent medical examiners" by insurers. The frequency and extent to which IMEs report disability and need for treatment should be tracked, as well as the frequency with which their opinions are accepted following litigation.
  8. Administrative inefficiency must be eliminated. Hearing requests must be processed in a timely manner. Litigation should be discouraged in the absence of a "joined issue," as should duplicative or "investigatory" testimony. Depositions should be eliminated in favor of in-person testimony, or restricted to extraordinary circumstances. To the extent that depositions are retained, regulatory guidance must be provided as well as real-time access to a WCL Judge to obtain rulings on disputed matters. Reserved decisions should be issued within 30 days. Appeals should be decided within 60 days.
  9. A worker-friendly culture consistent with the intent of the statute should be encouraged on the part of Board personnel, including WCL Judges. In the current environment RFA-2 forms are treated as credible, while RFA-1 forms are treated with skepticism. Insurer lack of compliance is routinely excused. Current statutory and regulatory provisions are inconsistently enforced.
  10. The Medical Treatment Guidelines should be withdrawn.
  11. The 2012 Guidelines should be applied as intended, and supplemented with a consistent mechanism that creates predictability of claim values and which can be effectively implemented by WCL Judges and attorneys.

Attorney

9/12/2013

We change our car oil every three thousand miles or so to prevent break downs. We get immunization and yearly physical and screening to prevent and manage illnesses.
Today I ask the questions," What are stake holders doing to prevent work place injury and what discussion is being raised in preventing work place injury in the BPR project"?
Workers' Compensation Board employee

9/12/2013

I understand you are looking for ideas for this new project taking place. I think that if anything can be done to simplify the WC process overall, that would be helpful. I know the Board has made strong efforts to make things better with the 2007 reform however, I don't see things moving along fast enough. I know in my own organization this is true as well. For example, I am certain that overall there are many files out there that may be ready for permanency that aren't moving forward with the caps.

I have seen a positive impact with the Medical Guidelines however, the number of forms and days to respond gets very confusing and needs to be more simplified.

Notice of Case Assembly – I am not sure this is needed.

I am not saying we should revert back to the old days however I would love to see things more simplified. I would like to hire people with no experience and train them from the ground up but I shy away from this as things have become way too complicated. I am afraid a new hire would not be able to grasp everything quick enough.
Third Party Administrator

9/9/2013

  1. NY seems way more lenient than other states.
  2. The window to respond to claims is very short, which also seems to be designed to increase leniency.
  3. NY has stricter rules around the doctor the patient can choose and patient-doctor-employer communications. It can be difficult to get enough information from the doctors to determine follow-up actions and accommodations for the worker. This often works against the worker. Many workers want to get things settled and get back to work so they can get overtime and get back to the regular jobs. Doctors often think they're doing the worker a favor by extending restrictions, but it often ends up hurting the worker's chance to work at their normal level.
  4. Having a doctor that is already setup and familiar with the company and work environment can make the whole process smoother and faster for worker and employer.
  5. It can take a very long time for workers claims to get processed. Not sure where the delays in the system are, but this can become very problematic for workers making alimony payments.

New York State Employer

9/6/2013

I have a workers compensation case that was decided in my favor by the Administrative Law Judge on March 7, 2013. The insurance company … appealed the decision and since then, there has been no word on my case. I have called a couple of times and all I get is "it's still in the appeal process". The last call I made I was told it could take up to a year! I find this utterly ridiculous that people are left "hanging" for that amount of time… I just can't believe that the process is that far behind and can take that long. The insurance companies can "play" the system because they can always appeal and in the mean time not have to make any payments. They know the system and how long it takes so by the time a decision is made, they have avoided payments for close to a year. I truly believe something has to be done to correct this system.
Injured Worker

9/6/2013

I have a workers compensation case that was decided in my favor by the Administrative Law Judge on March 7, 2013. The insurance company … appealed the decision and since then, there has been no word on my case. I have called a couple of times and all I get is "it's still in the appeal process". The last call I made I was told it could take up to a year! I find this utterly ridiculous that people are left "hanging" for that amount of time… I just can't believe that the process is that far behind and can take that long. The insurance companies can "play" the system because they can always appeal and in the mean time not have to make any payments. They know the system and how long it takes so by the time a decision is made, they have avoided payments for close to a year. I truly believe something has to be done to correct this system.
Workers' Compensation Board employee

9/4/2013

I do all the scheduling of doctor testimony at the Buffalo Board. The biggest complaint I hear is that the bills do not get paid in a timely manner. I talked to a doctor's office in Alabama yesterday and she said that in Alabama if a bill is not paid within a certain amount of time they can charge interest. They were very disgusted with New York Comp as they had bills dating back to June 2012 that were not paid, they contacted the Insurance Company numerous times to no avail. Needless to say the doctor refused to testify until the bills get paid. That holds up the claimant's compensation case.

A suggestion would be to allow the doctor's office to charge interest when a bill is not paid within a specified amount of time. Maybe then the Insurance Carrier's /TPA's will pay timely.
Doctor's Office

9/4/2013

With the MG-2 process the doctor's have to jump thru hoops to get alternative care such as physical therapy, massage therapy, and chiropractic care authorized, that it's just easier to write a prescription. In 90% of the phone calls I get from claimant's it is that they don't want to "pop pills", but they can't get alternative care authorized. New York State does not recognize the importance of that.
Workers' Compensation Board employee

9/3/2013

NYS is an employee choice state except if the employer has a certified PPO network. With such a network the employer can direct care for the first 30 days. This would be a big benefit to employers and injured workers. It is vastly underutilized by employers for two reasons – one the requirement that if an employee is subject to a collective bargaining agreement than the union must ratify the use of the PPO and the second reason is attached. This is the report the WCB requires all employers who use a PPO to fill out and submit to the WCB quarterly. The report is onerous, over burdensome and designed to discourage employers from taking advantage of one of the very few tools we have to control costs and outcomes. I guarantee no one at the WCB even looks at these reports. It is a total waste of time.
Third Party Administrator

8/29/2013

With the implementation of the ICD-10 codes in October 2014 I would like to suggest ICD-10 codes be used when an injured party has a body party established by the Workers' Compensation Board. The treating physician should outline which ICD-10 codes are related to the workers' compensation claim.

Thank you for the opportunity to provide my feedback.
Third Party Administrator

8/26/2013

The NY WCB has too many forms. If there is no controversy, there should be no need for a hearing. Too many cases are indexed when there are no disputes.
Your goal should be to eliminate 90% of the forms or accept the information in electronic formats.

Example – C-240 is the injured workers' payroll history. Payroll for each week must be filled out individually for the previous 52 weeks. Most other states will accept 13 weeks or 26 weeks. Furthermore, the WCB will not accept an electronic printout of an employee's wages, all information must be put on the C 240. This is extremely burdensome for employers. As is the C2 and the requirement that they be maintained for 18 years.
Third Party Administrator

8/21/2013

Please sit before reading this shocking story: NY State is asking for our input in improving the NY Workman's Comp policies and processes in New York. If you have any ideas you can send them to me and I'll compile them, or send them directly to BPR@wcb.ny.gov. Please pass this along to anyone that you know has passion, ideas or involvement with the New York Workers Comp processes, including those outside of …

Now there may only be a small chance that our suggestions get enacted, but there will be zero chance of any improvements occurring if we don't speak up. It can only get better if people get involved to make it better.

You can read the official solicitation here: http://www.wcb.ny.gov/content/main/SubjectNos/sn046_608.jsp
New York State Employer

8/16/2013

I have been an Orthopedic Surgeon for 50 Years.
I have been doing large numbers of IME examinations for the past nine years.

Right now, the injured worker has no stake in his recovery. The longer he is out, the more treatment he has, the more he complains, the more he is rewarded. The more operations a surgeon does, the more he is rewarded.

The WCB should consider a system such as DRG's in hospitals, where a claimant gets a set amount of money early, and can spend it on necessary medical care, or keep it if he choses. Surgeons should be capitated for their services. The worker and his employer should be rewarded for early return to work.

I would be glad to help in the design of a better system for the rendering of orthopedic care.
Doctor

8/16/2013

Off the top of my head, it would be a good idea if we could search the database using the NYWCB number and/or the claimant's first name and/or Date of Injury or Date of Disablement. Sometime it is awhile before a NYWCB # is assigned and it might be helpful to look up if something is received by a party of interest, what else might be there. Another situation arises when you have taken over the handling of a file from a now-defunct TPA or insured or the insured changed TPA's and you are acquiring files. No NYWCB number is listed or indicate anywhere on the documents. It would be great to be able to look this up and obtain a NYWCB Number on a claimant.
Third Party Administrator

8/15/2013

With e-claims roll-out recently, the WCB is moving is the right direction. Many other agencies; including the federal government; their forms can no longer be printed out and mailed in. It's all done electronically, including electronic payments. You go to their website, complete the form on-line, give them your banking information, the form and payment is completed electronically, you print off a copy of the form you just completed along with a transaction confirmation. The Board should be moving in that direction, at least for the forms being completed by doctors, insurance administrators and employers. I realize many people do not have computers, not connected to the internet or have slow or limited internet service, so all the forms cannot be sent electronically.

So many of the forms completed, especially by the doctors and employers, even the insurance administrators, are incomplete. E-claim will not permit administrators to submit forms if certain criteria is missing. Those forms will be "transaction rejected". Certain forms on the Board's website can also be arranged to do the same thing, if information is missing, it will not be able to be submitted. Most doctors' offices, insurance administrators and employers usually do have internet access. They should be the ones who have to and need to submit electronically. This would definitely limit the use of obsolete forms into our system. The Board doesn't have to worry about electronic payments, only electronic forms …

As I had stated above, to expect "everyone to submit forms electronically" is not being realistic. But what is realistic..... having the doctors, insurance administrators and employers submit electronically. It would eliminate many problems that are incurred now.
Workers' Compensation Board employee

8/15/2013

I represent self-insured employers and I often communicate with claimants' counsel between hearings and resolve issues. I often ask the WCB to issue administrative decisions pertaining to agreed-upon items and the WCB (or the claimant's attorney) almost always insist on holding a hearing where nothing gets accomplished other than putting the agreement on the record. Claimants' counsel are often reluctant to agree to administrative decisions because they are afraid their fee application will be reduced because they did not attend a hearing. I would like to see the WCB facilitate settlements without the need for hearings which take a long time to schedule, and cost the employer money to send an attorney to put the agreement on the record.
Attorney

8/15/2013

I am a provider. NYS Comp used to be complex. Now it is unbearable and extremely inefficient. I predict that may Providers will drop out of the program in the future. Comp cases take about 3X as much work as comparable no fault or private insurance cases

Some suggestions from a Provider's perspective:

  • grant access to the ECF in order to review pending hearings and get copies of notices that have not been sent, etc…
  • give the Provider standing to adjudicate billing issues, i.e. request hearings on C8.1's etc…email to examiner re specific issues that need to be addressed.

Doctor

8/14/2013

… I know in … NY, we have lost many doctors who refuse to treat workers' comp patients. They don't want to be a part of this system. Why?

I know my primary doctor doesn't take workers' comp patients and when I asked him why, he said because it takes forever to get paid by the carrier.

Just some thoughts I wanted to share.
Workers' Compensation Board employee