One Way *New* New York Workers Compensation Treatment Guidlines Can Help Employers

The NY workers compensation board has in existence four new sets of treatment guidelines for the back, neck, knee and shoulder. These sites account for the majority of all serious claims. The guidelines can be seen on the Board website.

 

 

All four sets contain an identical section A.19 which provides that a treating physician may request a chance to inspect the work site “to obtain information regarding the demands of the patient’s pre-injury job”. The physician can then estimate a level of disability based on actual job duties rather than the old, universal “mild, moderate or marked” disability. (WCxKit)

 

 

The guidelines recognize that few doctors will trouble to actually view the worksite, even though that provides the most accurate information.

 

 

The employer, whenever there is a serious injury, should immediately send the treating doctor a letter asking if the doctor will be requesting an “on-site inspection”. Copies should be sent to the Board and carrier. In nearly every case, no inspection will be requested.

 

 

However, if there will be medical testimony taken, the carrier/employers examining doctor should make a brief visit to the work site prior to testimony. The doctor will then be in a position to answer what the doctor saw in the workplace that supports the report’s conclusion.

 

 

Such testimony will be far more powerful that merely assuming (or guessing) or taking the word of the worker as to what the activities are, even though such speculation has been the rule for decades.

 

 

If a treating physician should make a rare appearance they should be welcomed. Treating physicians are seldom accorded such treatment and are more likely to be sympathetic to the employer’s point of view when they receive it. (WCxKit)

 

 

An end to the practice of having experts testify “in a fog or a vacuum” will be beneficial to both the employer and the employee.

 

 

Author Attorney Theodore Ronca is a practicing lawyer from Aquebogue, New York. He is a frequent writer and speaker and has represented employers in the areas of workers compensation, Social Security disability, employee disability plans, and subrogation for over 30 years. Mr. Ronca has 21 years experience in searching and retrieving medical records and many other types of documents for defense of workers compensation claims. Contact Attorney Ronca at 631-722-2100 or medsearch7@optonline.net. 

 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

 

California Medical Provider Networks

California allows the workers compensation insurers and self-insured employers to utilize a Medical Provider Network (MPN) for the treatment of on-the-job injuries and work-related illnesses. The MPN is an association or network of clinics, physicians, hospitals and other medical providers – under contract with the MPN – who treat workers compensation injuries and occupational illnesses.  The advantage of the MPN to the employer is the employee is treated by a medical provider who specializes in work-related injuries.
Some practitioners have noted with criticism
, however, that not all doctors in the network are well-qualified and further indicate that “almost  any physician who is willing to take a discount” can get on the panel; therefore, it is important for employers to make sure that the doctors in their networks understand workers compensation, know how to bill at the OMFS (official medical fee schedule), know how to write reports and return injured workers to modified work. Physicians who are not experienced in the nuances of workers compensation may also not know how to close a case appropriately: Released as Cured; Pre-Injury or Permanent & Stationary / MMI.

 


California MPNs 
are designed to provide services throughout the state. It is customary for the MPN to offer:

  1. A primary care physician within 15 miles or 30 minutes of the employee’s residence or job site.
  2. All other medical services within 30 miles or 60 minutes or the employee’s residence or job site.
  3. Emergency medical care services.
  4. Medical care in rural areas (they have alternative distance and time standards and, in some situations, allow out-of-network medical providers or non-contract medical providers).
  5. Medical care for the employee who is working or traveling outside of their home geographical area (but still within the State of California.)  (WCxKit)

 


It should also be noted 
that all physicians in or out of the MPN must follow the California Treatment Guidelines / Medical Treatment Utilization Schedule Reg. 9710.

 

 

The employer has the opportunity to direct the care for 30 days with or without an MPN, but the requirements must be strictly followed or the injured workers regains the right and ability to self procure his own medical provider at the end of 30 days; if the employer has followed the rules, they retain right to direct care for the life of the claim. Stated another way, if an employer has an MPN and did not follow the procedures at time of hire and again at time of injury they lose the right of control. The employer can direct care for the first visit and if they have complied with requirements for providing the employee with MPN information and a list of providers at the time of hire and again at the time of injury they have control for the life of the claim.  If the employee is unhappy with the choice of a physician, they can elect to change doctors but must stay within the MPN.


If the employee is unhappy
 with the diagnosis or the treatment they receive for their injury, they have the right to ask for a second opinion from another physician within the MPN. The employee is required to make an appointment within 60 days of requesting a second opinion. If the employee is unhappy with both their original doctor’s opinion and the second doctor’s opinion, they are entitled to a third opinion in California.

 

 


If the employee is unhappy
 with the first opinion, second opinion, and third opinion, the employee may file a request for an Independent Medical Review (IMR) with the California Division of Workers Compensation administrative director. The administrative director will assign an independent medical reviewer. The independent medical reviewer will conduct either a physical examination or a medical-records review. If the independent medical reviewer agrees with the employee, the employee can select a physician who does not have to be a part of the MPN. In this case, the employer/insurer is responsible for the medical care cost. The injured worker can request a “QME” (Qualified Medical Examination) and will be provided a panel of 3 to choose from in a given specialty or specialties.

 

 


Most MPNs
 will offer medical management in which a nurse case manager will work with the employee, the employer, and medical providers to get the employee back to work as quickly as feasible. Some MPNs also offer a vocational specialist who works with the employee to retrain them for another occupation when they are physically unable to return to their prior job.

 

 


An insurance company
 or self-insured employer can create their own MPN or join one of the MPNs that have already been established. The benefits to the employer who joins a MPN include:

  1. Lower medical cost– The MPN contracts with the medical providers for the cost of the medical fees which are lower than the Medical Fee Schedule used in California. On average the medical fees are approximately 10 percent lower through a MPN.
  2. Medical control throughout the claim – When an employer has a MPN and complied with the requirements, the employee must treat within the MPN throughout the life of the claim (with certain exceptions, see above) unless the employee has pre-designated their primary treating physician (the large majority do not). Employers need to make sure this information is provided to all new hires, at the time of hire. They need to be able to document compliance.
  3. Elimination of chiropractors and acupuncturists: if the employer has a MPN, the employee can only pre-designate a medical doctor or doctor of osteopath. Without a MPN, the employee can pre-designate their chiropractor or acupuncturist. However, the injured worker can under 4601 request chiropractic care or acupuncture within the MPN. If the MPN has no panel chiropractors or acupuncturists within the given geographic distance they can choose one outside the MPN.

 

 

Medical Provider Networks provide medical cost control. The long term impact for the employer is lower overall cost of workers compensation insurance. We recommend for all California employers have a Medical Provider Network, or be affiliate with an insurance company that has one, and make sure you are in compliance with the rules.


Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

6 Things Adjusters Wish Their Clients Knew

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When adjusters daydream, their non-work daydreams are like every one else – romance and money. But when they are about work, many dreams are about how much easier life would be if their clients – the employers – knew what they know. If you could see inside the adjuster’s head, here are some of the things the adjusters wish their clients knew:

 

5 Things Adjusters Wish Their Clients Knew:

 

  1. You Hire Too Many Druggies

Workers compensation adjusters know that from 38 to 50 percent of all workers compensation injuries are related to substance abuse, according to the Tennessee Department of Labor. The adjuster’s biggest wish is that their clients had a drug-free workplace program. When employers have a published drug-free workplace program that includes pre-employment drug screens, random drug testing and mandatory drug testing of all employees involved in a work-place accident, the number of work-related injuries drops sharply. Hence, the adjuster daydreams about every employer having a drug-free work place and because of that, having a lot less workers comp claims to work on. (WCxKit)

 

 

  1. Safety saves you Money

One of the first things the work comp adjuster does when a new work comp claim is assigned to him or her is to read the Employer’s First Report of Injury (FROI). The FROI has a section for the employer to describe what happened. When the adjuster reads, “Employee hurt back lifting ________ (fill in the blank),” or, “Employee tripped over ________ (fill in the blank),” or, “Employee was struck by __________ (fill in the blank),” the adjuster recognizes what the employer does not see – the employer’s safety program needs improvement. Lifting, tripping, and being struck by something are all types of accidents that can usually be avoided with an enforced safety program in place. The adjuster wishes the employer knew how many fewer accidents there would be (and how much lower the work comp premium would be) if the employer had an enforced safety program.

 

 

  1. Treat Every Little Injury

Too often, the adjuster gets to handle the mess the employer made when they decided not to report a “minor” injury. The employee may have said he could “tough it out” when he strained his back, twisted his knee, or dropped 200 pounds on his foot. The untreated injury often gets worse before it gets better. Just like the old proverb “a stitch in time saves nine,” timely medical treatment for a small injury can prevent an employee from aggravating the injury and making it more serious. The adjuster wishes employers would send every injured employee immediately to the doctor (and while the employee is being treated, get the drug test done as there is often an alternative motive for “toughing it out”).

 

 

  1. Keep in Touch with the Employee

The smart work comp adjuster knows the employee is another human being, and, just like almost every person, the employee wants to know that someone, anyone, cares about the injury that has occurred. The big burly roughneck is not going to think,” My employer is compassionate,” if he never hears from the employer after an accident. What he will think is, “They don’t give a damn (or insert much stronger curse word) about me,” and off he goes to get a lawyer who will listen to him and who will “make sure the employer pays for this.” The adjuster daydreams and wishes that the employer would stay in touch with the employee after an accident, sharply reducing the number of lawyers involved in their claims.

 

 

  1. Keep in Touch with the Adjuster

The adjuster needs to know what the employer knows about the work comp claim. If the employer hears scuttlebutt that the employee’s accident happened at home, or that the employee could return to work but does not want to, or any other information about the claim, the information should be shared with the adjuster. The adjuster’s daydream here is the simple wish the employer would keep the adjuster informed of any developments.

 

 

  1. Modified Duty Saves Money

While physical therapy will assist the employee’s recovery from musculoskeletal injuries, often-light duty work will do the same thing, and is a whole lot cheaper for the employer in the end. When the adjuster calls the employer about the employee returning to work on light duty, and has to deal with a supervisor who is only thinking about what is convenient for the supervisor, the adjuster sighs. When the employer refuses to accommodate light duty, the adjuster wishes the employer knew and understood how much sooner the work comp claim would be over if the employer would put the employee back to work on modified duty. (WCxKit)

 

 

Workers comp adjusters do not daydream or wish the employer knew everything about their jobs, but the adjuster will continue to wish the employers understand how the employer’s action or inaction affects the adjuster’s job. If you want the adjuster to feel yours is a wonderful company, heed the ideas expressed above.

 


Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com.

 

 

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SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

 

New York Workers Compensation – Are Guidelines Good

Employers of all sizes, businesses great and small, have hoped for good cost containment measures to be implemented in New York. A state where businesses have left, sometimes in droves, due to high taxes, the workers compensation insurances costs are seen as another burden for them.
 
 
In 2007, then Governor Spitzer successfully negotiated acceptance of sweeping changes in the Workers Compensation Law. This came after years of complaints and was the new hope for reduced premium costs. There were many important changes: a cap in all permanent partial disabilities including head, neck and back injuries; an increase of lost wages benefits for the injured workers; final and irrevocable lump sum settlements; and a plan for new medical treatment guidelines which could curb the ever-rising costs of medical treatment. (WCxKit)
 
 
While the Workers’ Compensation Board and the Rating Bureau artificially pushed a reduction in premiums as a result of the new legislation, this was short lived. For the most part, the cost containment benefits of this new law could only be realized over the next two years as new claims under the law came up for conclusion. However an immediate reduction was necessary. Politically, in order to satisfy the stakeholders.
 
 
Unfortunately, the WCB now some three plus years post-implementation is now just getting around to implementation. The premium costs began to rise again in 2009. Then last summer, the Board came up with a draft of the Medical Treatment Guidelines. It was released to all by October 2010. Better late than never, or so we thought. All the parties have been in an uproar as the WCB implemented the guidelines on December 1, 2010. The trouble is that no one was or is ready. Medical providers are not up to date with the requirements. Claimants and their attorneys are in an uproar as the Treatment Guidelines vary severely from the actual medical practice of the last thirty years. Insurance carriers and self-insured employers have had no time to adapt their computer systems or train their case managers and adjusters based on the new guidelines.
 
 
Over the last three decades, the WCB moved from employing a medical director to firing all physicians employed by the Board. Now, in the wake of 9/11 and the legislative changes they have again hired, though part-time, a physician to act as a medical director for the WCB. Though late, this is a good change for an organization whose judges make medical decisions affecting injured workers. Regarding the all-important caps on the period and extent of permanent partial disabilities, the WCB judges began assessing permanency and establishing caps for disability over the last nine months, and the process is slow, as most require negotiations by the parties before a law judge will make a findings. All of this has caused an increase of costs for many businesses and insecurity for the medical providers and injured workers. Expectedly, this is far from the “win-win” expectation announced in 2007.
 
 
So, the New York State Workers Compensation System is at a turning point of change, either for good or for — let us say — not so good. It is too soon to tell just yet what the outcome will be. As all stakeholders struggle to get a handle on the new Treatment Guidelines, we expect to see many requests by medical providers for a Variance from the Guidelines. As an example, a three-year-old permanent claim is now handled like a new injury as of December 1st, 2010 for treatment purposes. Assuming the Guidelines approve 8 weeks of chiropractic treatment or 6 weeks of physical therapy with an expected standard of the condition resolving, those who have been getting symptomatic treatment one time a month will be cut off from continued treatment at the end of January. Those who find it impossible to live (financially) once their disability payments are capped (a future issue), will also have the ability to ask the WCB for continued indemnity payments because of their financial hardship. (WCxKit)
 
 
The employers in New York do not feel secure about their workers compensation system, either their premiums or the welfare of their employees. It is just too soon to tell where we will be when all the dust settles in the coming year.
 
 
Author/Consultant: Eileen Wojnar (our newest contributor) completed a 34-year career for the New York State Insurance Fund, as Assistant Director of Business Operations. She is a graduate of CUNY, earning a BA in communications from Hunter College and an MS in Education from Queens College. She also holds the designation of Workers Comp Professional. She can be contacted at e2wojnar@aol.com.

 

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Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@ReduceYourWorkersComp.com

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