Comments Received Through Email
There needs to be a change in benefits paid to injured workers.
-They need to get their indemnity benefits started much sooner than they do, carrier's wait too long to respond to indexing notices and send checks when there is evidence of a disability.
-How the rate of indemnity payments is determined needs to be changed. A person gets paid based on the % of their disability even though you may not be 100% disabled you may not be able to go to work or your employer may not allow you to return to work until you are able to work full duty. This leaves an injured worker out of work, unable to support himself because he's getting a fraction of what he normally makes, but he cannot return to work. There should be a healing period set up for different injuries that allows an injured worker to get paid 100% if they cannot return to work, rather than only paying them what their disability is and forcing them to return to work before they are healed. If an injured worker can work light duty but the employer has no light duty, then they should get paid at 100% disability rate. It is not reasonable to expect an injured worker to get paid based on their temporary disability and expect them to seek other employment within those restrictions if their current employer cannot accommodate them when the disability is only temporary. There should be a period of time set up for various types of injuries that protects the worker and allows them to heal while being able to pay their bills and support themselves, so they can return to work and not sustain another injury. The current policy forces them to return before healing because they cannot support themselves or to find new employment within their restrictions for an injury that is only temporary. Someone who has surgery gets paid at the total rate automatically for a couple months because it's assumed they are totally disabled from surgery, then as they start to heal they get paid less and less. Imagine you break your leg have surgery, and you're slowly healing, but you cannot get yourself to work or you need the use of your leg at work, but because you are healing and you have the use of other limbs you are not considered totally disabled, so you do not receive your full indemnity checks, but your household bills and expenses remain the same. The injured worker cannot return to work or the employer cannot accommodate them within their restrictions, but the injured worker is paid based upon a disability that is not truly applicable.
First and foremost is that I have had an appeal, regarding equitable apportionment of attorney fees, pending for eighteen months now. I have been told the final decision was made over a month ago and is in final review. Something must be done to streamline these processes. In many cases, peoples' lives are on hold, pending these decisions. In MOST cases the claimants' life situations are deteriorating rather than improving, while they await these decisions. Then they must worry about the carriers appealing AGAIN or bringing up some other frivolous issue to delay paying. It is no secret that it's in the carriers' best interests to hold out as long as possible in hopes that the claimant dies and the case just goes away…. It also seems to me that the carriers should be held to a higher standard and be subject to more severe penalties (to the benefit of the claimant) for excessive frivolous actions and any and all false statements they make (which can be proven). The carriers are the major hurdle for revamping the system.
To incentivize carriers to pay without prejudice, HIMP should work in reverse: carriers should be able to recover from the primary health insurer when it pays on a controverted claim that is later disallowed or it pays for non-causally related treatment. Under ACA most people should soon have standard health insurance.
- Copayments – after claimant has reached MMI. Value to health care system same as private health care- allow under as Health Care Savings Account tax deduction.
- WC Billing form - HICFA 1500 as payment mechanism of provider similar to forms they use with other insurance
- Creams and ointment therapy are costing employers over 1,000 per jar…have not been approved by FDA. Many unaware TPA's are just paying these- while in MTG's having monthly reminders and updates of issues such as this may be helpful to carriers implementing MTG's evenly
- Bring back full apportionment of temporary lost time and medical. WC system is letting private health insurance, other forms of insurance off the hook – we could use the offset and many times an injury is truly a combination of prior conditions and work related events. This worked in the 80's and 90's – downside is it would promote litigation….however savings to WC system. Defined rules may prevent litigation i.e. prior surgery to same body part.
- Claimant attorney should not be allowed to bring up getting IME late…AFTER testimony is taken. Waste of WCB's time.
- Adjuster licensing and continuing education needed- beyond carrier/TPA 50-3b license
Direct all providers to submit all medical bills to payers electronically.
This is the wave of the future in WC billing. Electronic submission of medical bills is already mandatory in Texas, California and Minnesota. As Director of Claims at NYSIF I saw this done with great success for over 5 years. Bills are vetted before submission so that are "cleaner" and are therefore paid more quickly and with greater accuracy. The interface used by NYSIF is web based and is also able to submit narrative medical reports.
The problem is that there is not nearly enough market penetration on the provider side. Some hospitals and doctors are notoriously slow to change their ways. It is ridiculous that in 2013 most bills are still submitted in paper form. Providers can be given plenty of time to comply, say, two years. They may howl, but it's time to drag them into the 21st century. They'll thank you in the long run.
I believe the Board is trying to make the future Claims process automated. So I was wondering if CIS can be programmed to automatically request medical evidence on new incomplete (without medical) claims, using the same programming that issues the EC-1.2 if a claim is dormant. Especially on claims with a C-2 and/or C-669 or the new FROI/SROI forms.
I am a provider and I am writing to recommend some improvements to the system. They are as follows:
ECF: If the claimant gives authorization, a provider should have access to the ECF. Continuity of care is compromised when patient records are unavailable. Lack of access to other medical records in the ECF such as diagnostic tests may result in duplicative and unnecessary services. Also, it is frustrating and time consuming that every time a provider needs a notice of decision (often these are not sent to the provider), the provider has to call the Board or call the attorneys' office. Providers should have access directly to the ECF if the claimant grants authorization to access. Such access could be included in a revised Form OC-110A.
The ADR, PPO & ROC programs and Diagnostic Testing Networks are confusing to everybody. There should be a form created (similar to DT-1) that informs the injured worker of their rights as well as any requirements to adhere to these various programs. This form should be signed by the claimant (or unsigned with proof of mailing) and filed in the ECF so that it is available for access.
C8.1: Lastly, there is extensive litigation at the Board pertaining to C8.1's against providers, mostly billing related. However, the provider does not have standing to initiate or participate in the adjudication of these bills. The claimant's attorney is typically involved in these disputes, but they are the claimant's attorney, not the provider's. Providers should have the right to due process in these cases and/or the right to retain their own counsel (with commensurate attorneys' fees due from the carrier, similar to the NY no fault statute). Additionally, the provider should be on notice of any appeal that concerns these C8's and the outcome of that appeal.
As a provider, I can tell you without a doubt, that providing medical care for a patient under the NYS WCB system involves triple the work for the same patient if not work related. I believe that these 3 changes would go a long way towards improving the system. I would have liked to participate in the prior BPR teleconferences but I was too busy filling out MG-2's and C4Auths and HP1's, LOL but not kidding.
Child Support Arrears. The Board needs to be more proactive with detecting whether a claimant is past due with respect to child support. Most often, this comes up when a case is ready to be settled. In some instances, I have seen where a claimant denies that he has child support arrears (at a hearing or on Board forms) and then receives a large 32 settlement. While CIS is equipped with a Dependent Search feature, it is only effective if a Board employee actually uses it. Ideally, we would have a system in place that automatically notifies the claims examiner that a claimant has a CS obligation and if there are arrears. That way the WCLJ would not sign off on a settlement until such time as the CS obligation has been satisfied, in accordance with WCL Section 33. I know that some local criminal courts for example, find out on their own if there are CS arrears and will not sign off an a plea agreement until such time as they have been satisfied.
The most critical change required at the Workers' Compensation Board is to inject a sense of reality and practicality into the process and the outcomes. There are numerous examples where plain common sense and day to day reality are ignored in favor of convoluted self-sustaining rationales that lead to results which, in any other context (including a trial by jury), would be deemed impossible as having no basis in reality.
One such example is the anti-intuitive, but not uncommon, accepted wisdom at the Board that surgery, in and of itself, will increase the value of a schedule loss of use award. This is in direct contradiction to the commonsense notion that people generally have surgery to improve their condition and, further, that most surgical outcomes decrease, rather than increase, one's degree of disability.
By way of example, there is a file on my desk at this very moment in which the claimant's IME opined, prior to the surgery, that the claimant had a 15% SLU. The claimant subsequently underwent arthroscopic surgery. Thereafter, his surgeon concluded that, despite what was characterized as a successful surgery, the claimant now has a 55% SLU. The judge so found.
Under no other circumstances is it possible to believe that someone who underwent successful surgery, had physical therapy, incurred less than a month of lost time and returned to a physically strenuous job would have a more disabling condition than they had prior to the surgery.
Again, this goes to one of the most fundamental problems at the Board . . . no reality check. Most people know someone, either young or old, who has had some sort of arthroscopic surgery. Most of these people return to their jobs and activities of daily living with little or no deficits. Generally, they feel better than they did before the surgery. That is the practical experience in the world.
Yet this reality is not mirrored by the reality of the Board. Instead, at the Board, surgery intended to improve a claimant's condition, de facto increases their schedule loss of use.
Workers are intimidated. They face retribution for speaking to anyone or for even filing a claim. They are terrified of filing claims.
How are you collecting data, how are you using it to focus on PREVENTION?
Police officers and Firefighters are entitled to full benefits under General Municipal Law with full wage replacement and medical treatment paid for. This is a direct cost to the municipality and there is no process in place under workers' compensation that recognizes that with a self-insured municipality there is no actual reimbursement when awards are made. This is simply a paper award but in fact adds another cost to the municipality when they must pay the attorney fee.
- I had three requests today for information. The first two were both from Special Funds regarding the current diagnosis, medications prescribed and the reason for the medications on two long standing cases. In both instances I had previously sent an office note both to Special Funds with all the identifying information and with the diagnoses, medications and the reason for the medications not once but twice. No one seems to read the material we send them so I have re-attached the appropriate office notes and sent them back. For one of these patients she has been denied her medication she has been on for about 5 years since July for no reason. It also is redundant for me to have to send the same information more than once. The third request was from an attorney who is asking for the very same information that was in the office notes I had already sent to him and I have sent it yet again. This is the wasted time and effort that will drive me and others out of the workers' compensation system.
- . . . . Many of the patients I see are chronic cases. The last one who left the office dates to 2001 for a back injury. My frustration is that in our rush to "close" cases, we are forgetting that there are many injured workers who have chronic problems and will need treatment forever. I use the example of a simple below knee traumatic amputee. Once the surgery is done and the wound is healed, his medical care is all but done and the case is at maximum medical improvement. However, the care will go on forever. In all our technology we have yet to develop a way to re-grow a limb so his need for prosthesis and skin care and perhaps pain management will be permanent. Likewise, I think that we are looking only at the medical side of many cases. While many injured workers may have a permanent partial disability based on measured impairments recognized in the guidelines, they almost always have some potential to return to some form of work. To achieve this however requires vocational retraining yet I find that my referrals to VESID often go unheeded and that the "case managers" either ignore the idea or refuse to consider anything that is not "medical". I do not find that the current guidelines or the guide to permanent impairment give significant weight to vocational training, transportation and education which are the tools that would help many injured workers.
What has happened with the new guidelines is that the burden of proof has shifted. A carrier can now deny almost anything and the provider has to identify the specific chapter and section of the guideline to try to make a correction. It would be far better for the carrier to have to define what specific guideline section they are using to make a denial and allow us to respond.
- Access to the Electronic Case Folder for our cases only, information can be limited to upcoming hearings, Notices of Decision, general case info.
- Ensure that we are a party of interest on all of our cases and receive all notices of decisions by just sending in our first PS-4 or an OC110A. I wouldn't have to call the WCB so often. I find out about psych nod's months, sometimes years later. I was told that the carrier has to send in a c-8 .1 for us to become a party of interest. Speaking of that, a hearing isn't set for us unless a c8.1 is filed.
- Maximum Partial Rate for Schedule Loss Awards–Can we bring back a maximum partial rate for schedule loss awards? Insurance carriers, premium payers, self insureds and tax payers all suffer the unintended consequences of the abolishment of the maximum partial rate for schedule loss awards. Absence of a maximum partial rate makes perfect sense for disabled folks who are losing time and have no income. It makes no sense, however, to grant awards at the total rate for permanent PARTIAL schedule loss awards extending beyond periods of lost time.
Example: A worker loses 12 weeks from work and receives a post surgical schedule loss evaluation of 22% of the arm. This equals 68.64 weeks of benefits payable at the total weekly rate of $850 amounts to an award of $58,000 tax free dollars! A reasonable solution would be to award the 12 weeks of lost time at the total rate of $850 and the remaining 56.64 weeks at a partial rate of $425 (1/2) for a total award of $34,277. Let's bring back the maximum partial rate for schedule loss awards. This type of award was never intended to be paid at the total rate.
- Change the Schedule Loss System–Why not save money and time by streamlining the schedule loss system? Under the current system we have IME doctors and Lottery doctors giving extreme opinions in opposite directions. Why not put together a state panel of workers comp doctors specifically trained in the guidelines who can perform schedule loss evaluations. The evaluation could be sent to all parties and a NOD (notice of decision) could be rendered. If either party felt there was an evaluation mistake, a request could be made for an impartial specialist. This system would greatly reduce IME expenses as well as the expense of paying for a "Lottery Doctor's" SLU opinion. We can also do away with the unnecessary treatment the "Lottery Doctors" prescribe in order to get paid under a treating doctor status. Under the current rules their evaluation fee wouldn't be payable otherwise. Claimants shouldn't be subject to unnecessary appointments in order to get their award. A well trained schedule loss panel would reduce costs and save time by removing the friction caused by conflicting medical opinions. A single evaluation would result in less hearings, less depositions, less appeals. Claimants would receive their money sooner with less effort. This is a win for claimants, Insurance carriers, self insureds, tax payers, premium payers and the State of New York. A well trained panel of doctors could also solve the well known problems associated with permanent partial disability classifications.
- Permanent Partial Disability Classifications–Does anyone understand the guidelines associated with permanent partial disability classifications? Why not create a well trained state panel of workers compensation doctors who could evaluate and timely resolve classifications with consistency?
Creation of a Spanish Work Group. It appears that Spanish speaking claimants make up most of the Board's non-English speaking group. I believe it would prove to be efficient to create a Spanish speaking Customer Service Representative and Claims Examining Work Group to handle and assist those claimants. This would eliminate the extra time it takes for someone like myself to get an interpreter on the line and still struggle to assist these callers. These calls take longer. This work group could also handle documents submitted in Spanish. The current document translation process is not user friendly and very time consuming. There are serious delays in trying to process a claim when you need to have a document translated. Once done, you're still unclear as to what's what in a file. This would most likely result in cost savings and avoid delays.
My suggestion is more towards ensuring compliance on a larger scale - statewide. I believe it will benefit the Worker's Compensation Board to initiate the process of issuing employer's numbers at the onset of a company's registration. Irregardless of the need to purchase workers' compensation insurance, it would be good if every entity that registers to do business in New York State also obtain a worker's compensation EMPLOYER'S number.
- Change to the C-4 Auth Process–A physician is required to ask for carrier authorization, using a C-4Auth, for 13 procedures outlined in the MTG. WCL §13a (5) provides that such request can be denied only based on a second medical opinion (IME). If a physician has not followed the MTG by omitting a required procedure (such as physical therapy) prior to the authorization request, the carrier cannot deny authorization based on MTG deviation. Rather, the carrier must obtain a second medical opinion (IME) to deny. When the IME report states that the physician did not follow the MTG, the carrier objects to the C-4Auth and files a C8.1A objecting to treatment, which then requires a hearing. This is contrary to the purpose of the MTG. This process:
- Delays treatment - 30 days for IME + 20 days for an expedited hearing + possibility for deposition this could be anywhere from 60 to 90 days.
- Increases hearings
- Increases cost to carriers. IME's can cost between $375.00 and $1,500.
The carrier should be allowed to deny a C-4 Auth without a second medical opinion on the issue of deviating from the MTG. This change would provide for:
- Faster treatment to the claimant - as the denial would go out long before 30 days and the doctor would be made aware of what was needed.
- Decrease in hearings- as C8.1A's would not be necessary.
- Decrease in costs to carriers - as second medical opinion would not be needed for the IME doctor to advise that the physician did not follow the guidelines.
- Repeated decisions on same issue, same doctor, same treatment–If a carrier or special fund denies payment to a bill for treatment not recommended under the guidelines (C-8.1B) and a decision is rendered on that bill. All future bills for the same treatment and same provider should be denied on the same basis without another hearing. Facilitated by decisions stating what bills are denied for what treatment and why, rather than just saying C-8.1B for carrier.
A change in this process would:
- Reduce the number of proposed decisions/meetings.
- Verify the treatment that was not recommended.
Impartial Specialist Cases. Currently there are 2 doctors on the list of doctors who have applied to be Impartial Specialists. One is an orthopedic surgeon who had to be begged by the agency and the other is a cardiologist. Prior to changing the system earlier this year I had a healthy list of doctors in many specialties in much location. Your new system dramatically lowered the fee and now it's impossible. I have a claimant who has been waiting since April .. to get scheduled for an examination. My suggestion .. Go back to the old system where Doctors could charge what they thought they were worth, but you can keep the new forms.
Every other week lately, I have a claimant who misreads the Hearing Notice time. For example the hearing is set for 2:00 PM 45 minutes and the Claimant reads this as 2:45 PM. Has anyone given thought to redesigning the Hearing Notice so that the hearing time and hearing duration are not written right next to each other.
I am a clinical social worker in Rochester Occupational Health Clinic Network sites in Rochester, NY. In my position, I see the multitude of negative effects suffered by Workers Compensation patients. The financial hardship, loss of functioning, excessive scrutinizing by surveillance and IMEs lead to depression and anxiety in the majority of people who have been out of work for an extended period of time.
Due to the low reimbursement, the uncertainty of payment, and the tedious paperwork, psychiatric providers who will treat comp patients are almost non-existent. In Rochester, there are no privately practicing psychiatrists accepting Workers Compensation. Workers Compensation will only pay or recognize board certified psychiatrists and clinical psychologists. While the Office of Mental Health (OMH) clinics do accept Workers Compensation, since the OMH restructuring several years ago, most clinics do not offer stand alone appointments with psychiatrists and require regular visits with clinic therapists who are generally clinical social workers or other Masters' level practitioners and, therefore, not payable under Workers Compensation.
If a mental health condition is accepted under Workers Compensation, they no longer have the option of using regular health insurance or even privately paying and cannot receive psychiatric treatment. This is unsafe and debilitating mood problems increase pain and create barriers for return to work.
In 2008, the NASW proposed legislation where Licensed Clinical Social Workers would be authorized to provide care and treatment under the Workers Compensation Program. If this change occurred, it would create the opportunity for Workers Compensation patients to received treatment in a community mental health center.
Also, reduced requirements for tedious paperwork would make it more feasible for practitioners to accept Workers Compensation. On most compensation cases, the mood/anxiety component is secondary to the injury that occurred at work. As such, a visit note, DSM-V diagnosis, and a statement of limitations/treatment progress should be sufficient to justify payment for the visit and medication prescribed.
That being said, if patients did not have delayed treatment and payment of benefits while waiting for the insurance company to adjudicate, a significant portion of the mood issues could be avoided. ERISA guidelines exist for the adjudication of disability claims and should apply to Workers Compensation as well.
- Notice of Decision for each case should contain more case information – information such as AWW and listing of accepted injury sites should be included with case information already on the bottom of the NOD.
- M&T reimbursement needs to be standardized – Some insurance companies use Mapquest or some other method to determine mileage, but this information can vary and does not necessarily reflect actual routes -- not every insurance company agrees on what it will and will not reimburse, and reimbursement is only available to those who request it, but not all claimants are aware of it. A system should be devised so it is automatic and available to all, or be done away with and the saving put into something more useful, such as a guaranteed fitness membership (see below).
- YMCA memberships should be automatic for a six month period once initial period of physical therapy is completed. After that period it can be renewed if determined to be useful and worthwhile and if it is being utilized regularly by the claimant, which can be verified by attendance records at the facility.
- Get rid of use of third-party vendors for prescription issues by insurance companies -- especially for apportioned claims, there are several instances where IC authorize medication but third party vendor will not fill medication because of billing issues -- it deprives claimants of their rights to medical benefits of claim.
- WAMO is severely understaffed and over a year behind on processing claims, which is contrary to the purpose it was created to do, which is to settle more claims in a more timely fashion.
- Medicare set-aside calculations delay potential settlements for at least six months. Perhaps there should be another agency or entity that can provide the service other than Medicare, or even more radically have lifetime medical benefits converted to Medicare responsibility after some pre-determined time.
- There have been many instances where older comp cases, especially those with previous SLUs, seek treatment and when the doctor tries to verify if a claim is open because of lifetime medical benefits, they are instead told the claim is closed when it is only inactive. This again defeats the purpose of the lifetime medical guarantee and claimant's right to treatment. Although lifetime medical treatment sounds like a wonderful benefit, in practice it proves less effective if many physicians will not take old compensation claims or if insurance companies do not readily allow treatment for older cases that are inactive for a period of time.
- The Licensed Representative test has not been given for six years, it should be given on a more consistent basis, if not yearly then at least every two years.
- Apportionment of claims should be handled as they are in Section 44, that is that the most-recent insurance company should be responsible for administering the claim for payment of indemnity and medical expenses, thus the claimant should only have to deal with one insurance company. Let that carrier get reimbursement from the other apportioned carriers instead of making the claimant have to deal with two or more insurance companies with different policies.
- Proposed Decisions and Reserve Decisions that allow for 60 to 90 days to get permanency opinions should be standardized to only 30 days. If insurance companies can be compelled to get IMEs within 30 days to address issues for variances, they can do so for permanency opinions as well.
Thank you for your time in considering these ideas to improve the workers' compensation system.
- Clear communication to injured workers about the existence of the workers' compensation system, availability of benefits, rights (including the right to counsel) and obligations.
- Timely delivery of indemnity benefits to injured workers; consistent and effective penalties for non-compliance.
- Strict enforcement of injury reporting and filing requirements.
- Medical reporting that transmits necessary claim information without imposing undue burdens on health care providers.
- Initial formal hearings that ensure worker access to benefits in all cases.
- Access to high-quality medical care resulting from outreach, regulation, and fee schedules that encourage provider participation.
- Consistent interpretation and enforcement of statutory and regulatory provisions.
- Discouragement of frivolous litigation.
- Timely scheduling of hearings when required.
- Testimony before the trier of fact to enhance credibility determinations.
- Timely decision of claims at the hearing level and on appeal.
- Data collection to inform public policy, legislation, regulation and administration.
- Professional and respectful communication among the agency, injured workers, employers, insurers, and attorneys.
If the State is truly interested in improving the system for all stake holders than I would suggest that to go forward we take a step back. Specifically, bring back the Board's doctors to handle all issues of medical care. These could be handled off calendar through record review and address the overwhelming number of C-8.1s, variance requests, and C-4 Auths that over load our system by resolving them off calendar. Their findings would be binding on all parties allowing only the claimant an opportunity to request testimony if the treatment was denied. This would allow hearing calendars to be able handle other critical issues far more quickly so that the claimants get their awards in a more timely manner and carriers can have inappropriate awards suspended and adjusted more quickly. Also if hearings are able to be allocated the proper amount of time the number of hearings for each claim should decrease as well. With the lowering of the number of hearings the Judges can also be given additional time to be off calendar to issue decisions on other issues that would also normally require a full hearing (saving all parties the time and expense of coming to a hearing). Full hearings could than be used for the critical issues that really do need to be addressed quickly (ANCR, ODNCR, suspension of benefits, additional sites, fraud, etc...)
In addition, and in accordance with taking a step back, eliminate the overwhelming documentation that all the parties need to complete. The C-4 form should be a simple 2 page document that can easily contain all the required info as it once done and eliminate the multiple C-4 documents that now exist and plague the doctors treating the claimants, the carriers, and our own claims department. The same can be said of the C-3. Of course electronic versions should also be narrowed down to single universal forms.
Somewhere along the line, in attempts to make the process more streamlined, the Board has overwhelmed the claimant, carrier, and its own employees in a sea of paper that takes far too much time to file, process, and review.
I have been extremely concerned regarding the failure of the NYS Workers Comp program to timely resolve cases and provide needed financial support to patients injured during employment. Recently, I witnessed a close family friend who has to cash out her retirement funding to pay for an unresolved Workers Comp case. This unresolved case has gone on already over 16 months without resolution or payment in sight for lost wages as well as ongoing medical care The individual has received numerous favorable Workers Comp decisions on various levels from different judges but the process allows the large corporate defender to file ongoing multiple appeals without payment. The individual has been examined and found to have sustained numerous ongoing work related injury claims by two NYS licensed physicians, a Licensed Therapist as well as confirmed by an independent Medical Examiner Psychiatrist selected by the NYS Workers Compensation board. Cases like this represent a total miscarriage of justice and frustrate the real intent of the NYS Workers Comp program to provide timely payment for clearly justified injuries sustained during employment attributable to corporate negligence. On a personal professional level I have discontinued taking NYS Workers Comp patients due to the excessive paperwork reporting requirements, inadequate fee schedule, and difficulty receiving timely payment of claims.
Currently the Parties of Interest are not linked in any way. It would be helpful, save time and possible 110-a violation if the employers were linked to their insurance carriers in CIS.
When something is denied, I as the treating physician do not learn of the denial from the carrier but instead from the patient or in some cases the pharmacy. If the carrier is going to deny, THEY should have to quote the chapter and section of the Guidelines to justify their denial. Then and only then can we make a reasonable response to the denial. If I choose to deny based on one section but they have denied based on a different section, we simply go round and round.
I think there should be a mechanism for having the claimant paid after a hearing. I heard that there was such an arrangement in the past. Now in this day and age it should be doable.
Stakeholder type not indicated
We could really use a database that is name searchable for doctors whose code letters were pulled by the Board and the date those code letters were rescinded. It would also be helpful to claimants and other stake holders to have access to this type of database as well.
- 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.
- 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 hyper-technical 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- The Medical Treatment Guidelines should be withdrawn.
- 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.
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
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
- NY seems way more lenient than other states.
- The window to respond to claims is very short, which also seems to be designed to increase leniency.
- 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.
- 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.
- 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
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.
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.
Workers' Compensation Board employee
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.
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
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
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
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
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:
New York State Employer
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.
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
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
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.
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.
… 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