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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207
Governor David A. Paterson


Subject No. 046-435

Board Publishes Proposed Regulations Adopting Medical Treatment Guidelines

Date: July 6, 2010

On June 30, 2010, the Workers' Compensation Board published proposed regulations that would make the revised medical treatment guidelines ("Guidelines") mandatory for providers, employers, and insurance carriers in the workers' compensation system. The Guidelines, incorporated by reference in the proposed regulation, cover the treatment of workplace injuries involving the knee, shoulder, neck, and back.

The Guidelines are an important component of the 2007 workers' compensation reform. They were initially formulated by the Governor's Workers' Compensation Reform Task Force and its advisory committee ("Task Force"), which included well credentialed medical professionals appointed by business, labor, and the Insurance Department. Over the past year, the Board's Medical Director and staff have reviewed and updated all four protocols in light of comments received by the Board and recent developments in medical literature.

The revised Guidelines are posted on the Board's website.

A summary of changes from the original Guidelines developed by the Medical Director's Office is also available.

The Guidelines set forth the recommended standard of care for treatment of workplace injuries based on established medical evidence and the consensus of experienced medical professionals. The Guidelines do not authorize certain medical procedures that are ineffective and place limits on the timing, frequency and use of other diagnostic tests, therapeutic treatment, and surgical or medical treatment that are recommended.

The goal of the Guidelines is to improve the quality of medical care, speed the delivery of medical treatment to injured workers, reduce litigation and friction costs, and eliminate unnecessary and potentially harmful treatment. Guidelines have reduced medical costs in other state workers' compensation systems by reducing ineffective or unnecessary medical care and improving the quality of care provided to injured workers.

The proposed regulations formally adopt the Guidelines as the standard of care for treatment of workers' compensation injuries to the knee, shoulder, neck, and mid and low back. Most diagnostic testing and medical treatment within the Guidelines are deemed pre-authorized if performed in accordance with the Guidelines and, therefore, not subject to prior authorization by the employer or insurance carrier. Certain recommended treatments, including several complex surgical procedures, do require prior authorization from the carrier or employer.

The regulations allow a treating doctor to seek a variance to provide care that is outside the parameters set or procedures addressed in the Guidelines. To apply for a variance, the treating doctor must show that additional treatment beyond the Guidelines is justified based on objective measures of patient improvement or that treatment outside the Guidelines is necessary and effective based on individual circumstances and/or compelling medical evidence.

The regulations also include an optional prior approval process that allows a treating provider to request a determination from a participating carrier or employer that the requested treatment is a correct application of the Guidelines.

In addition, the proposed regulations amend the interval of when physician's medical progress reports need to be filed. Progress reports must only be filed when a follow-up visit is necessary, however, the intervals between medical report filings should never exceed 90 days.

The regulations are posted on the Board's website for public review. Anyone may comment on the proposed regulations. Comments will be accepted until the close of business on August 16, 2010. They must be in writing and submitted to Cheryl M. Wood, Special Counsel to the Chair, by mail at NYS Workers' Compensation Board, 20 Park Street, Room 400, Albany, NY 12207 or by email at regulations@wcb.ny.gov.

The Board will offer web-based training on the Guidelines for medical professionals, attorneys, medical office staff, and claims staff and adjusters, starting in September 2010. More information on the training program will be posted on the Board's web page when available.

 

Robert E. Beloten
Chair