New York Workers' Compensation is an intricate area of law that is often subject to a number of misconceptions. This site is intended to help readers seeking clarification on the topic of NY Workers' Comp. Whether you are an injured worker lost amidst the complexities of Workers' Comp, a doctor who is not sure how to properly handle a Workers' Comp patient's file, or simply a curious New Yorker who worries about what would happen if you were ever injured on the job, I hope that the content of this site will deliver the answers you seek, even to questions you didn't know to ask.

It is my pleasure to welcome you into the world of New York Workers' Compensation. I hope you enjoy your visit, spread the word, and come back soon.

Best regards,

Camila P. Medici, Esq.

Thursday, December 16, 2010

Carriers' Roles Under the New Medical Treatment Guidelines

Carriers will have to designate a qualified employee who the WCB can contact about variance requests.  These contacts will be published on the WCB's Website.  This is designed to help the Health Care Providers so that they know who to send their variances to. 

Carriers have to decide whether they will obtain an IME or review of the records report.  If the Carrier plans to obtain either an IME or a review of records report, they must notify the WCB of that intention within 5 days of receipt of the variance request.  If the variance was sent by e-mail or fax, the received date is deemed the same date of transmission, whereas if the variance was sent via mail the received date is five days from the date of postage.  The Carrier notified the WCB of their intention to obtain an IME or review of the records by completing section "D" of of the form MG-2. 

If the Carrier does not plan on getting an IME or review of the records report, the Carrier must notify the WCB within 15 calendar days after receipt of the variance request.  If the Carrier has chosed to get an IME or review of records, the Carrier must issue a responde to the varriance request within 30 days of receipt of that variance request.  Since this creates a huge burden on Carriers, one suggestion has been to get examining physicians to set aside one day per month for these varriance requests. 

1) Approval.
2) Denial - Denials must be issued even if the Carrier has already filed a C-7 controverting the case.  Controverting the case is not enough to constitute a denial of the variance. 
3) AuthorizeWithout Prejudice - available only if the claim has been controverted or the time to respond has not yet expired.
4) No response - if a Carrier does not respond within the time allotted the Chair will issue an Order of the Chair.  This decision will likely result in an approval of the variance.  An Order of the Chair issued for no response or for an untimely response is not subject to an Appeal under WCL Sec. 23.

Denials must be fully explained by the Carrier under Section "E" of form MG-2.  Any reason for denial that is not explained is waived.  There are 4 possible grounds for denial:
  • Treatment requested has already been rendered
  • Health Care Provider did not meet burden of proof
  • Treatment requested is not medically appropriate or necessary (must be supported by an IME or review of the records report)
  • Claimant failed to appear to a scheduled IME. 
If the Carrier's denial is based on the treatment not being medically necessary or appropriate, the Carrier must have had the request examined/reviewed by an IME or records reviewer, must attach the IME reports or review reports, and must submit citations to peer-reviewed medical journals in support of the denial. 

1 comment:

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