Category Archives: Workers Compensation

Denying Medical Treatment Guidelines Variance Requests: What Carriers Need to Know

Effective December 1, 2010, treatments for injuries to the mid and lower back, neck, knee and shoulder are governed by the Medical Treatment Guidelines (“MTG”) in New York State.  12 N.Y.C.R.R. 324.2.  Amendments were made to the existing MTG, and guidelines for carpal tunnel syndrome, as well as ongoing maintenance care guidelines were incorporated effective March 1, 2013.  On December 15, 2014, further amendments were made to the MTG, and guidelines for non-acute pain were also incorporated.

The MTG simply lays out recommended treatment for the injuries that it governs.  However, there are times when the medical provider believes treatment that varies from the MTG is medically necessary for the claimant.  In such a situation, the medical provider must submit a proper request for authorization of varying treatment. 12 N.Y.C.R.R. 324.3.  The request for authorization must be made using the MG-2 and MG-2.1 forms, and must be done prior to rendering the treatment.  The provider is not allowed to submit a request after the treatment is rendered.  In addition, the medical provider has the burden of proving that the varying treatment is medically necessary. Continue reading Denying Medical Treatment Guidelines Variance Requests: What Carriers Need to Know

Evaluating Claims for Exposure in New York

Join us for our monthly webinars on New York and New Jersey workers’ compensation law. Click here to register. Here is the post-webinar video from our most recent presentation, “Evaluating Claims for Exposure in New York.” The complete archive of prior presentations is here.

Subject: Permanency, LWEC, SLU, Exposure, New York
Date Presented: November 16, 2015
Presenter(s): Timothy Kane, Esq., and Greg Lois, Esq.
Run time: 44:18

New York Electronic Data Interchange (“eClaims”) and “Monitoring and Compliance” Initiatives

The Board’s new 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?).

Timeline of the “Typical” case: Admitted Traumatic Accident with Lost Time.

  1. Initial investigation to confirm loss.
  2. If there is medical and lost time, begin benefits.
  3. File FROI-00.
  4. File update EDI documents as the case progresses.

The process in detail.

Investigation and Communication.

All accidents should be investigated fully. The employer should contact the insurance carrier and maintain those communications throughout the claim. The investigation’s results should be copied to your defense attorney in the case of a controverted claim.

Continue reading New York Electronic Data Interchange (“eClaims”) and “Monitoring and Compliance” Initiatives

Getting the most from your IMEs in New Jersey

Join us for our monthly webinars on New York and New Jersey workers’ compensation law. Click here to register. Here is the post-webinar video from our most recent presentation, “Getting the Most From Your IMEs in New Jersey.” The complete archive of prior presentations is here.

Subject: Independent Medical Examinations, New Jersey
Date Presented: October 26, 2015
Presenter(s): Greg Lois, Esq.
Run time: 26:10

When Should a Medicare Set-Aside be Submitted to CMS for Approval Before Settlement?

Medicare is a federally sponsored health care plan that is available to individuals who are; a) 65 or over, b) to individuals who have received Social Security Disability Insurance (SSDI) benefits for more than two years, and c) to individuals with end stage renal disease. It is common for workers’ compensation claimants to be Medicare recipients.

The Medicare As Secondary Payer Act (Link) has made it clear that if medical expenses could be covered under either workers’ compensation or Medicare, workers’ compensation, and not Medicare, should pay. Workers’ compensation is primary and Medicare is secondary. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). Continue reading When Should a Medicare Set-Aside be Submitted to CMS for Approval Before Settlement?

Consent with regard to Section 29 lien rights

Under NY WCL Section 29, a Workers’ Compensation carrier has the right to recover its lien against a negligent party who caused injury to the claimant.  Since the idea of Workers’ Compensation is to streamline benefits to the claimant immediately after the injury, the Workers’ Compensation carrier must pay benefits accordingly and expeditiously.  The idea is to have the Workers’ Compensation carrier rest easy knowing that if a negligent third party is involved in an injury, the right to subrogate and the right to recovery is protected by statute. Continue reading Consent with regard to Section 29 lien rights