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Can Carriers Control Where NY Claimants Receive Prescriptions and Diagnostic Tests?

The balance between the right of the employee to choose their own medical provider and the right of the carrier or employer to have some control over the cost and quality of treatment in Workers’ Compensation case is often in conflict.  There are two areas were the carrier or provider can maintain some control over the cost of quality of care.  Workers’ Compensation provisions allow the carrier to mandate use of contracted pharmacy or diagnostic testing facility as long as certain procedure is followed.

Prescribed medicines.

NY Work Comp L § 13(i)(5) allows an employer or carrier to contract with a pharmacy contract to provide prescribed medicine to claimants.  Under the provision, the employer or carrier may require claimants to obtain all prescribed medicines from the pharmacy with which it has contracted, except if an emergency occurs and it would not be reasonably possible to obtain immediately required prescribed medicine from the pharmacy with which the employer or carrier has a contract.

If the employer or carrier requires claimants to obtain prescribed medications from the pharmacy to which it has contracted it must notify claimants of the pharmacy or pharmacies with which it has a contract, the locations and addresses of the pharmacies and how to initially fill and refill prescriptions through the mail, internet, telephone or other means.  It must also specify what required information must be supplied to the pharmacy.
If the contracted pharmacy does not have mail order service or a physical location within a reasonable distance from the claimant, the claimant may obtained prescribed medicines at a pharmacy of their choice and the carrier will be liable for such charges in accordance with the fee schedule.

Diagnostic testing.

Additionally, the employer or carrier may require the claimant to obtain these diagnostic tests from the network that has the contract [NY Work Comp L § 13-A]. However, a procedure must be followed.  At the time a request for authorization for special diagnostic tests, x-ray examinations, magnetic resonance imaging or other radiological examinations or tests costing more than one thousand dollars is approved, the insurance carrier must notify the physician requesting authorization of the requirement that the claimant obtain or undergo the test with a provider or at a facility affiliated with the network or networks with which it has contracted. It must provide the contact information for the network and a list of the providers and facilities within the claimant’s geographic location, as defined by regulation of the board. The claimant, in consultation with the provider who requested the test will determine the provider or facility from within the network which will perform the test.

12 CRR-NY 325-7.3 mandates a number of requirements to become a diagnostic testing network.  It requires any diagnostic testing network in contract with a carrier to file detailed information with the chair.  A partial list of the required documents include basic organizational documents of the network, the names it is registered with the department of state, the names under which it conducts business, address of any office it conducts business, telephone number of each location, the network and affiliated provider’s tax ID number, a contact person for the network, a copy of the proposed contract between any affiliates, a copy of proposed agreement with the carrier, a description of services provided, a list of all address where tests will be performed.    It also mandates each diagnostic center be available 8:00 AM to 6:00 PM Monday through Friday.

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