New York workers’ compensation reform confusing to medical providers

Since 2007, New York state has significantly reformed its workers' compensation laws that govern the provision of medical treatment to injured employees. Physicians and other medical professionals who treat patients with work-related injuries and illnesses are required to interpret and comply with intricate regulations and guidelines.

The Medical Treatment Guidelines

Starting on December 1, 2010, the Medical Treatment Guidelines, known as the MTGs, took effect, which made major changes to previous law concerning work-related injury and disease:

  • For work-related medical problems concerning the mid and low back, shoulder, neck, knee and, as of March 1, 2013, also carpel tunnel syndrome, the MTGs establish detailed testing, medication, therapy and other treatment recommendations that treating medical professionals are mandated to follow.
  • As long as medical treatment of problems in these body systems complies with the MTGs, no preauthorization by the insurance company or the New York State Workers' Compensation Board is required. Previously, all treatment costing more than $1,000 required insurer preauthorization; that requirement now only applies to treatment concerning body systems or problems other than the five covered by the MTGs.
  • Even within the five body systems covered by the MTGs, nine particular procedures always require preauthorization, as does any proposed repeat of a previous surgery that was not completely successful.
  • Doctors are not required to follow the MTGs in the delivery of emergency treatment.
  • With most insurance carriers, medical providers have the option of requesting optional preauthorization even if the proposed treatment seems to fall within the MTGs.
  • When a doctor believes an injured employee needs treatment that departs from that dictated by the MTGs, a variance may be formally requested of the insurer.
  • Particularly controversial is the regulation of "ongoing maintenance care programs" like physical or occupational therapy under the workers' comp law. Basically, the treatment is only allowed if the patient has improved as much as possible and has permanent disability, chronic pain and will lose function without it. Such treatment is limited to ten times per year per affected body part.

Official policy

The MTGs were meant to promote objective healing and the ability to return to work by standardizing medical care within the affected body systems, which concern a large portion of all workers' comp claims, and to save costs and speed proper recovery, according to the New York State Workers' Compensation Board.

Interestingly, the Board says on its website that if treatment is not within the MTGs and a variance is not obtained, the treatment may not be provided at no charge by the doctor, nor can the patient receive it and pay privately outside the workers' compensation system.

The law sets out complex review and appeal procedures before the Board for denied authorization and variance requests.

Seek legal advice

This article only scratches the surface of the new MTGs and other changes to the New York workers' comp medical care delivery system. Unfortunately, medical treatment has become so complex in workers' comp cases that both injured workers and their medical providers are sometimes confused about how to proceed under the new laws. While the changes were supposed to make things administratively easier, that is not always the result in practice.

Any injured worker who faces problems getting appropriate medical treatment should discuss it with an experienced New York workers' compensation attorney to better understand the law and determine whether an appeal or review is available, or whether any lawsuit options exist.