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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-497

Chair Proposes Medical Treatment Guidelines Addition and Improvements

Date: November 14, 2012

In December 2010, the New York State Workers' Compensation Board implemented a program of medical treatment guidelines (MTG) that fundamentally changed the delivery of health care to injured workers. The MTG program included four comprehensive, evidence-based guidelines for the treatment of injuries and illnesses involving the neck, back, shoulder and knee, with associated new processes for the implementation of the guidelines.

Since implementation, the Board has closely monitored the impact of the MTGs and regularly consulted with various stakeholders on their experience. Much of the feedback has been very positive, but like any process there are areas for improvement. The Board has worked with stakeholders to identify changes that would simplify the process, reduce disputes, and speed resolution of MTG-related disputes.

During this same period, the Board and system stakeholders have been hard at work to develop additional MTGs. In September 2011, Insurance Department Superintendent delivered a proposed MTG for Carpal Tunnel Syndrome (CTS) developed by the NYS Workers’ Compensation Reform Task Force and its Advisory Committee. In October 2011, I appointed a Medical Advisory Committee (MAC), consisting of the Board’s medical staff and nine physicians, three each appointed by Labor, Business and the Board. They have been working on comprehensive chronic pain guidelines, which are nearing completion.

Today I am proposing the first revisions to the original MTG regulations to take effect February 1, 2013. The revisions will:

  • Adopt the new CTS MTG as the standard of care for the treatment of injured workers with carpal tunnel syndrome;
  • Modify current MTGs to include new maintenance care recommendations; and
  • Implement consensus changes to simplify the process, reduce litigation and speed dispute resolution.

Carpal Tunnel Syndrome (CTS)

The new CTS MTG provide evidence based guidelines for the treatment of carpal tunnel syndrome, the most common occupational disease experienced in the workers’ compensation system. Like the other MTGs, the CTS MTG should improve the quality of care, speed access to the most beneficial treatment, and control the use of ineffective treatment.

Maintenance Care

The original four MTGs primarily address treatment for the acute and sub-acute phases of injury, with limited recommendations for the management of chronic conditions and chronic pain. As part of its effort to develop chronic pain guidelines, the MAC re-evaluated those recommendations that relate to maintenance care, recognizing that in certain situations maintenance care (chiropractic and occupational/physical therapy) should be available. The revised MTGs will authorize an ongoing maintenance program that can include up to 10 visits per year for those who have a previously observed and documented objective deterioration in functional status without the identified treatment. To be eligible for maintenance care, injured workers with chronic pain must have reached maximum medical improvement (MMI), have a permanent disability, and meet the requirements of the maintenance care program. No variance is allowed from the 10 visit annual maximum.

The new recommendations address a major concern of both providers and payers: the high number of variance requests. To date, more than three quarters of the variance requests are for maintenance care for those with chronic pain. Injured workers will now have access to important maintenance care while payers and providers will be relieved from the administrative burden of handling individual variance requests for this care. The remainder of the chronic pain guidelines is expected to be completed by early 2013.

Process Changes

The regulations also include several changes to simplify the process, reduce conflict, and speed dispute resolution. These consensus changes are the result of suggestions from stakeholders. The changes will achieve the following:

  • enable parties to more easily choose resolution by the Medical Director’s Office, which provides faster and less costly dispute resolution;
  • clarify and simplify transmission requirements that were resulting in rejection of thousands of variance requests for technical violations;
  • allow carriers to partially grant variance requests, thereby expediting care and reducing litigation;
  • eliminate submission of duplicate variance requests;
  • reduce the number of procedures requiring C-4 Authorization, and
  • authorize submission of variance requests through a web-based portal or other technology in the future, should it become available.

In addition, several changes to the Forms C-4 AUTH, C-8.1, MG-1 and MG-2 forms that have been agreed upon with stakeholders will be implemented.  Comments on the draft forms may be sent to formsdepartment@wcb.ny.gov and will be considered if received by Monday, November 26, 2012. Final versions of the forms will be posted in early December. The parties will be expected to begin using the new forms after February 1, 2013. Old forms cannot be used to initiate new requests after March 15, 2013.

Complete copies of the proposed regulations, new and revised guidelines, complete description of the process changes, draft versions of the new forms, and other information are available on the Proposed Changes to New York Medical Treatment Guidelines page of the Board’s website. The regulations will be published in the November 21, 2012 State Register.

Training and Questions

In 2010, the Board provided comprehensive training programs for medical providers, claim examiners, and others as part of the original MTG implementation. More than 53,000 courses were completed. Stakeholders praised the quality and availability of these programs, which helped facilitate implementation of the new MTGs. More than 90% said they would recommend the training to others, while nearly 70% recommended similar training programs be developed for future Board initiatives.

To facilitate compliance with the new standards and processes, the Board will provide additional training. Free, on-line programs are currently in development and should be available in mid-December. The Board expects to make continuing professional education credits available where possible. Additional information will be published as the training programs become available.

Answers to Frequently Asked Questions are currently available and will be regularly updated as additional questions are received. Questions may be sent to the Board at WCBMedicalDirectorsOffice@wcb.ny.gov.

 

Robert E. Beloten
Chair