AREAS & TOPICS PROTECTING THE RIGHTS OF THE INJURED AND DISABLED

Workers Compensation Medical Treatment Guidelines


 

INFORMATION ABOUT NEW YORK STATE’S WORKERS’ COMPENSATION

MEDICAL TREATMENT GUIDELINES

 

FAST FACTS ABOUT THE MEDICAL TREATMENT GUIDELINES:

  • Your access to treatment for your work-related injury is governed by New York State’s Workers’ Compensation Medical Treatment Guidelines IF you have a New York State workers’ compensation claim involving the back, neck, knees, or shoulders AND you live in New York State.
  • Your doctor must file an MG-2 form with the Workers’ Compensation Board and your workers’ compensation insurance company to obtain a variance from the Medical Treatment Guidelines.
  • Your doctor can file an MG-1 form to obtain the insurance company’s agreement that necessary treatment comports with the Medical Treatment Guidelines.
  • The Medical Treatment Guidelines can be reviewed online here: http://www.wcb.state.ny.us/content/main/hcpp/MedicalTreatmentGuidelines/2010TreatGuide.jsp

 

WHAT ARE THE MEDICAL TREATMENT GUIDELINES?

As of December 1, 2010 all workers' compensation claims in New York State involving the back, neck, knees, and/or shoulders irrespective of accident date are subject to a series of new Medical Treatment Guidelines. The stated purpose of the Medical Treatment Guidelines is to reduce litigation by pre-authorizing certain procedures that previously took up to 30 days to approve and often required protracted litigation as to medical necessity. In addition, the Workers’ Compensation Board sought to create with the Medical Treatment Guidelines a schedule of treatments for the back, neck, shoulders, and knees that are geared towards increasing and maintaining functionality with documented positive patient response. 
 

WHO IS AFFECTED BY THE MEDICAL TREATMENT GUIDELINES?

All New York workers’ compensation claimants who reside in New York State with work injuries involving the back, neck, shoulders, or knees, irrespective of accident date, are now covered by the Medical Treatment Guidelines. Even if your back claim was established in 1952, you are now covered by the Medical Treatment Guidelines. 
 

HOW DO THE MEDICAL TREATMENT GUIDELINES AFFECT YOU?

Click here to read the actual guidelines: http://www.wcb.state.ny.us/content/main/hcpp/MedicalTreatmentGuidelines/2010TreatGuide.jsp

As you can see it is now imperative that your doctor follow the Medical Treatment Guidelines if he or she expects to be paid for service. Failure to follow the Medical Treatment Guidelines is likely to result in non-payment of medical bills by the insurance company or suspension of treatment which can result in a great deal of pain and heartache for both doctors and patients. For example, you may be accustomed to visiting your chiropractor once a week without interruption. You may have seen your chiropractor every week for years! Now, however, your access to chiropractic treatment is governed by the Medical Treatment Guidelines which may limit chiropractic care to a maximum duration of three months.
 

WHAT IS THE VARIANCE PROCEDURE?

If proposed treatment comports with the Medical Treatment Guidelines your doctor in many cases will not need to apply for pre-authorization though he or she can file an MG-1 Form (found online here: http://www.wcb.state.ny.us/content/main/forms/MG1.pdf) to ask the insurance company or the Workers' Compensation Board to quickly agree that proposed treatment fits within the Medical Treatment Guidelines. If, however, proposed treatment does not fall within the guidelines he or she MUST file an MG-2 form (found online here: http://www.wcb.state.ny.us/content/main/forms/MG2.pdf) requesting a variance BEFORE he or she renders the treatment. A doctor’s request for a variance is literally a request by the doctor to render treatment that varies from the Medical Treatment Guidelines. The insurance company may approve or deny the variance request. If the insurance company denies the variance you or your lawyers must request a hearing with a Law Judge to adjudicate whether or not the variance should be granted by the Workers' Compensation Board. 
 

UNINTENDED CONSEQUENCES:

As with everything else that bureaucrats try to fix the introduction of the Medical Treatment Guidelines have had the unintended consequence of creating - literally - a brand new level of bureaucracy for workers' comp claimants to try to navigate just to get the treatment they obviously need! Recent reports confirm that the Medical Treatment Guidelines have vastly increased the amount of litigation over treatment issues: the Workers’ Compensation Board is holding an additional 15,000 hearings every MONTH just to handle the treatment issues created by the Medical Treatment Guidelines. Instead of authorizing treatment more quickly and readily the insurance companies and their lawyers are instead using the Medical Treatment Guidelines to deny treatment to deserving injured workers! Frequently, necessary treatment is denied only because doctors fail to file proper forms. It is now more imperative than ever that injured workers retain experienced legal counsel to help navigate the Workers’ Compensation Law. It is becoming increasingly clear that the system is intent on depriving deserving injured workers of the benefits they so desperately need.
 

HOW WE CAN HELP YOU!!

Since December we at Vincent Crusciolo and associates have handled many of these Medical Treatment Guideline issues and have won most of them.  We are intimately familiar with the entire process from start to finish. In many cases we are able to avoid court altogether either through effective negotiation or by ensuring that the Workers’ Compensation Board knows when the insurance company has improperly denied treatment. When it does become necessary to go to court we know the questions to ask and the arguments to make to get treatment authorized most of the time!! We also know how to advise patients and their doctors as to how to properly structure treatment plans to ensure compliance with the Medical Treatment Guidelines. Please call us! It is in your best interest. 

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Vincent J. Criscuolo & Associates
130 W. Main Street, Suite 220 Rochester, NY 14614
Phone: (585) 232-3240