Timeline of the “Typical” case: Admitted Traumatic Accident with Lost Time.
Initial investigation to confirm loss.
If there is medical and lost time, begin benefits.
File FROI-00 (Electronic Data Interchange, “EDI”).
File update EDI documents as the case progresses.
The Board’s initiative to enforce EDI (“eClaims”).
Beginning in 2013, the Board has begun an increased tempo of “monitoring and compliance” initiatives intended to enforce the eClaims guidelines and generate more penalty income for the State. The Board has now established a “Compliance Unit” intended to do the following:
monitor performance standards for timely submission of First Report of Injury,
confirm timely first payment of indemnity benefits,
check for timely submission of Subsequent Report of Injury showing first payment,
monitor timely submission of Controversy; and
track the Percentage of Claims Controverted (how many cases is the carrier denying?).
The New York Workers’ Compensation Board announced the creation of a Medical Portal to enable electronic submission of C-4AUTH, MG-1 and MG-2 authorization requests. The portal will provide users with real time status of requests and send a notification when a status changes. The Board claims that users will no longer need to know which form to complete when submitting a request and the portal’s user interface will ask the user questions, the answers will determine the correct path and type of treatment authorization request.
Use of the portal is not required
Health care providers may continue to submit requests using the paper forms, if they choose. It is anticipated, however, that electronic submission will make the approval process faster, reduce errors, improve data quality, and eliminate the need to submit paper authorization forms. Additionally, if a health care provider submits a treatment authorization request electronically, the payer will be required to respond to the request electronically. If the medical provider submits a paper form, the payer must respond in kind via paper submission.
The use of opioids is widespread in the treatment of numerous injuries in New York. Although prescribed by a number of doctors, great care must be taken when opioids are found to no longer be necessary. Recently, Judges have ordered both the carrier and the claimant to submit drug weaning programs when an IME doctor finds that the use of opioid drugs is no longer necessary for the claimant’s continued treatment.
What is a Drug Weaning Program and Why is It Necessary?
Use of Opioids: Transitioning/Managing Patients on Existing Opioid Therapy. The claimant’s physician must abide by the MTG recommendations to ensure that the management and treatment of a patient with non-acute pain is performed according to the principles for safe long-term opioid management and guidelines for optimizing opioid care pain (F.2.c [F.2.c.i-F.2.c.ii] and F.3 [F.3.a, F.3.b.i-iv, F.3.b.c.i-ii, F.3.d.i-iv, F.3.e.i-vi]).
Some of the MTG recommendations include: the need to routinely monitor the safety and effectiveness of treatment (improved function and pain control), an informed consent form (F.3.c), opioid understanding form (F.3.c.ii), appropriate monitoring and screening (random urine drug testing (F.3.d.i-iv), unannounced pill count(s), and evaluation and monitoring for adverse effects of and interactions with medications (F.3.b.i-ii and Table 3: Adverse Effects of Opioids). Continue reading Opioid Weaning Programs under the New York Non-Acute Pain Medical Treatment Guidelines→
A spinal cord stimulator is a system that uses implanted electrical leads and a battery powered implanted pulse generator to stimulate the back. A spinal cord stimulator is implanted in a surgical procedure that is not pre-authorized under the Non-Acute Pain Guidelines. Providers who want to perform this procedure must therefore request pre-authorization from the carrier before performing the procedure.
When is a Spinal Cord Stimulator Appropriate?
A spinal cord stimulator is prescribed for treatment of select patients with chronic back or neck radicular pain, specifically patents with failed neck or back surgery that have:
Persistent severe and functionally disabling radicular pain.
Been provided with conservative non-surgical treatments.
Undergone surgical treatment that failed to relieve symptoms and improve function and further surgery has been considered but not approved this time