If a treating physician does not follow the rules and the insurer is exempt from liability, will the Commission determine at the same time that the applicant is not responsible for the bill? The general principles describe functional performance assessment as a comprehensive or more limited assessment of various aspects of function in relation to the patient`s ability to return to work. A FCE may be performed without requesting a waiver if it is clinically appropriate for the injured worker, in accordance with the general principles of the Medical Treatment Guidelines, the guidelines and criteria set out in the basic rules of the New York Workers` Compensation Medical Expense Schedule. If a chiropractor and a physiotherapist perform treatment on the same day that complies with medical treatment guidelines and is billed according to the basic rules of physical medicine and chiropractic, are both physicians paid for the services provided? If a candidate deals with a chiropractor and a physiotherapist and both charge CPT codes, which are subject to the daily RVU limits in the fee schedule, both may not be paid. The insurer may object to invoices because of the parallel supply. Dealing suppliers may request arbitration, and the arbitration panel shall decide whether the services provided have been duplicated. If the physiotherapist and chiropractor offer different treatments, this is not considered simultaneous treatment. It is important to understand that the 2013 GTDs eliminate the need for variance to provide ongoing maintenance therapy for people with chronic pain. According to the 2010 JWGs, an injured worker had to request a diversion in order to waive permanent restrictions on treatment. The 2013 GMT allows for continuous maintenance (MOC) for injured workers who meet specific criteria. OMC is not simply a demand for 10 therapeutic treatments per year for all those who have achieved MMI. Treatment should be part of an ongoing maintenance program that includes a self-maintenance program, regular therapeutic withdrawal trials, and other features described in the guidelines. Waiver requests are no longer allowed for maintenance work. An expedited hearing involves referring a dispute to a workers` compensation judge.

The parties have the opportunity to testify medically (usually by testimony) before the judge decides the dispute. Either party may appeal the outcome of the hearing. Typically, it takes more than 60 days from the request for a hearing to the scheduling of the hearing and the adoption of a decision. For example, if six weeks of PT were approved by the insurer on 31.01.2013, the recommended frequency and duration restrictions for PT in GTD carpal tunnel syndrome would only apply after the end of the approved six-week treatment. If the services provided comply with the Guidelines and the corresponding CPT code is indicated in the Schedule of Charges for the Provider, the services are refundable subject to the RVU awarded and the restrictions of the Schedule of Fees. Treatment restrictions in MTG CTS will take effect in the same way as for PTDs of the back, neck, knee and shoulders in 2010.Treatments offered before March 1, 2013 or authorized by the insurer (via C-4Auth) before March 1 but after March 1 will not count towards the permanent treatment restrictions under the new GTD. Only therapies performed after March 1 or after the end of pre-approved treatment (before March 1), whichever is later, should comply with CTS-MTG treatment recommendations. Unless the CPT Code or the basic rule of workers` compensation in New York requires a report, a completed C-4 or C-4.2 report is all that is required. However, it is recommended that the provider also attach office notes to provide a clearer picture of adherence to medical treatment guidelines.

Work-related injuries that are not covered by the Medical Treatment Guidelines are treated as prior to the implementation of the Medical Treatment Guidelines. The provider must follow its normal standard of care and normal board rules and processes, including approval of treatment over $1,000. Yes. The regulations provide for an optional prior authorisation procedure under which the healthcare provider may request optional prior authorisation from a PARTICIPANT insurance institution to determine the correct application of the directives. The request for optional prior authorization from the attending physician and the carrier/employer response (Form MG-1) are available for this purpose on the Board of Directors website. Yes. A request for exemption would be required if durable medical equipment is not covered by the guidelines. Yes. A physiotherapist may complete the MG-2/MG-2.1 form(s), including guideline reference codes and supporting documentation of objective findings, and submit them to the treating medical care provider for review, approval and signature. Once the treating medical provider has approved and signed the forms, the physiotherapist may submit the completed MG-2/MG-2.1 forms on behalf of the treating medical provider.

The completed MG-2 must be presented to the insurance company or self-insured employer, the Workers` Compensation Board and the plaintiff`s legal counsel, if applicable, or to the claimant if unrepresented. If the insurance institution rejects the request for derogation on the grounds that the treating healthcare provider has not met the burden of proof that a derogation is appropriate and medically necessary for the claimant, the deviation may be examined by the designated contact point of the insurance institution. If the refusal of the derogation is for any other reason, the refusal must be verified by the doctor designated by the insurance institution. Yes. The Commission strongly encourages insurers and treating providers to informally resolve disputes related to medical treatment guidelines, including waiver requests. If the dispute is resolved through an informal discussion, the insurer must provide the provider and board with a signed copy of Form MG-2 indicating that the dispute has been resolved. No. This process is only available if the insurance company or employer participates in the optional pre-approval program. A list of insurance companies and employers who have opted out of the optional pre-approval process is available on the Commission`s website. Yes.

The guidelines apply to all private and municipal self-insured employers, self-insured group trusts, all special funds, the state insurance fund and private insurance companies. Lol Treatment guidelines do not need to be followed if emergency medical attention is needed. When the applicant`s symptoms and objective findings have subsided, no other treatment for that specific medical condition may be indicated. However, in case of exacerbation, treatment would be carried out in accordance with medical treatment guidelines. Do injured workers need to receive diagnostic tests from a diagnostic network for treatments covered by the medical treatment guidelines? What documents are required to participate in the ongoing maintenance program? Hospital officials should inquire about medical treatment guidelines. No written authorization is required to follow the guidelines. Treating medical providers may seek optional pre-approval from a participating insurer to confirm that surgery will be reimbursed. If the insurer does not participate in the optional prior authorisation, the provider may informally request authorisation from the insurer. No. Medical treatment guidelines are the standard of care in New York State.

If you wish to offer medical treatment that does not comply with the medical treatment guidelines, the treating medical provider must obtain a waiver from the insurer. If the deviation is not approved by the insurer or WCB, the treatment is not approved and should not be performed. Are hospital rehabilitation services required to use EO/PT-4 (version 12/10) report forms when billing for physiotherapy or occupational therapy services? No. If a medical adjudicator makes a decision on an optional application for prior authorization, that decision is not subject to administrative review under Article 23.The Board cannot provide legal advice on whether such decisions are subject to appeal under Article 78 CPLR. The new rules do not change the CPLR, so the question of whether the decisions of the medical adjudicator can be challenged through a section 78 proceeding will be governed by existing law. If a request for complementary treatment or maintenance care was previously rejected based on the 2010 guidelines, would the patient be entitled to an ongoing maintenance program? Depending on the injured body parts, one of the following may be admitted for treatment: a doctor, chiropractor, physiotherapist or occupational therapist.