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Glossary of WCB Terms
New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor David A. Paterson


Subject No. 046-456

Medical Treatment Guidelines Go Live

Date: December 1, 2010

Effective today, December 1, 2010, the Medical Treatment Guidelines become the mandatory standard of care for the mid and low back, neck, shoulder, and knee for dates of service on or after December 1, 2010.

The Medical Treatment Guidelines will:

  • Establish a standard of medical care for injured workers,
  • Expedite quality care for injured workers,
  • Improve the medical outcomes for injured workers,
  • Speed return to work by injured workers whenever possible,
  • Reduce disputes between payers and medical providers over treatment issues,
  • Increase timely payments to medical providers, and
  • Reduce overall system costs.

Variety of Training Opportunities Offered

It is essential for medical providers, insurers, legal professionals, and their staff to become familiar with the Guidelines. Free training is available via the Board's website by selecting "Medical Treatment Guidelines, Training" or going to: http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/Training.jsp (case sensitive).

Physicians are eligible for CME credits and chiropractors are eligible for CCE credits for completing these courses.

The Board continues to collaborate with stakeholder groups and provider associations to offer additional training opportunities, which will be posted on the Board's website. I encourage all system participants to take the available training to ensure a smooth transition into the new Medical Treatment Guideline process.

Certification by Carriers

Carriers are required to certify that they have fully implemented the Medical Treatment Guidelines by April 1, 2011. A carrier's Medical Treatment Guidelines' Administrator can make such certification electronically via the Board's website using the Administrator's log-in process and choosing Carrier Options and Certification.

Existing Claims – Frequently Asked Questions

We have received many questions about how the Guidelines will impact existing claims and previously scheduled or approved treatments. The questions and answers below reflect the Board's current guidance and are posted on the Board's website. Many additional questions are also posted on the website. Select "Health Care Information, Medical Treatment Guidelines, Frequently Asked Questions" or go to: http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/FAQs.jsp (case sensitive).

  • What if the claim is several years old and the injured worker has already received more than the recommended amount of physical therapy treatment? Do the Guidelines apply? Yes, however the Guidelines will be applied prospectively. Therefore, the Guidelines' recommended limits will apply to treatments on, or after, December 1, 2010. For example, if the doctor prescribes six weeks of physical therapy two times per week in mid-November, the portion of that therapy that occurs before December 1, 2010 is not subject to the Medical Treatment Guidelines. Beginning December 1, 2010, physical therapy may continue for up to three weeks and then, as required in the general principles of the Guidelines, the injured worker must be re-evaluated to determine if there is continuing objective functional improvement. Subsequent physical therapy must be consistent with the Guidelines or be approved through the variance process.
  • What if the claim is several years old and the injured worker has already received more than the recommended amount of chiropractic treatment? Do the Guidelines apply? Yes. All existing cases will not have the full documentation on objective functional improvement, therefore, medical providers and Carriers must follow the general principles and the Treatment Guidelines as if it is a new case. For example, an injured worker has been receiving chiropractic treatment two times per month for over a year prior to December 1, 2010. As of December 1, 2010, the Medical Treatment Guidelines apply; therefore, the injured worker must be evaluated at the end of a three week period to determine if there is continuing objective functional improvement. If the injured worker shows no objective functional improvement, additional chiropractic treatment would not be consistent with the Medical Treatment Guidelines.
  • If a procedure or test that requires pre-authorization was approved by the Carrier prior to December 1, 2010, but the procedure or test cannot be scheduled until after December 1, 2010, does the procedure or test have to comply with the Medical Treatment Guidelines? No. Any procedure or test that has been pre-authorized by the Carrier, by an Order of the Chair, or deemed authorized due to an untimely response from the Carrier, before December 1, 2010, can be performed and will be compensated, even if it does not comply with the Guidelines.
  • If a Workers' Compensation Law Judge had previously rendered a decision authorizing ongoing or symptomatic treatment, would the treatment have to follow the Medical Treatment Guidelines? Yes. The Medical Treatment Guidelines will apply to cases with orders for ongoing or symptomatic treatment. If such treatment is not consistent with the Medical Treatment Guidelines, the Carrier may object. If treatment exceeds the amount recommended under the Guidelines, the treating medical provider must show that there is a need for continuing treatment through the variance process.
  • What happens if a course of physical therapy has been authorized by the carrier prior to December 1, 2010, and it expected to continue beyond December 1, 2010? The Guidelines will be applied prospectively and will apply to treatments provided on, or after, December 1, 2010 regardless of when authorization was granted. For example, if the doctor prescribes six weeks of physical therapy two times per week in mid-November, the portion of that therapy that occurs before December 1, 2010 is not subject limitations contained in the Medical Treatment Guidelines. Beginning December 1, 2010, physical therapy may continue for up to 3 weeks and then, as required in the general principles of the Guidelines, the injured worker must be re-evaluated to determine if there is continuing objective functional improvement. Subsequent physical therapy must be consistent with the Guidelines or be approved through the variance process.
  • If a chiropractor is treating an injured worker one day per week prior to December 1, is the chiropractor entitled to treat three times per week beginning December 1 as recommended in the Guidelines? Only if three times a week is medically necessary in the treating provider's professional judgment. As of December 1, 2010, the Medical Treatment Guidelines will apply to whatever course of treatment is performed (i.e. one time a week, two times a week, or three times a week).

    Medical providers and carriers must follow the Medical Treatment Guidelines and general principles. Therefore, the injured worker must be evaluated at the end of a 3 week period to determine if there is continuing objective functional improvement. If the injured worker shows no objective functional improvement, additional chiropractic treatment would not be consistent with the Medical Treatment Guidelines.

Conclusion

The introduction of Medical Treatment Guidelines significantly changes the way medical care is rendered in workers' compensation cases. I strongly encourage all stakeholders, especially the insurance and medical provider communities, to communicate and cooperate with each other to make this effort a success. This includes using your best judgment in evaluating claims and approving appropriate and necessary care, including extensions of effective treatment, rather than requiring time-consuming, expensive litigation to achieve the same result. The benefit will be a better workers' compensation system for all stakeholders, especially injured workers, because care will be rendered more quickly, effectively and appropriately, while reducing unnecessary costs for all parties.

Please contact the Board at 1-800-781-2362 with any questions regarding Medical Treatment Guidelines. Thank you for your cooperation.

 

Robert E. Beloten
Chair