Medical Treatment Guidelines (MTGs)

A medical guideline has numerous names, including clinical guidelines, standard treatment guidelines, or clinical practice guidelines. It is a deciding framework constituting an appropriate diagnosis, course of management, and treatment course for specific medical specialties. In addition, a medical guideline frequently includes summarized consensus statements about healthcare best practices. Healthcare professionals must familiarize themselves with their profession’s medical standards and decide to implement treatment course recommendations.

The intent of an MTG is evidence-based standards of care and medical treatment best practices when treating work-related injuries. Physicians can guarantee that the insurance company will pay for medical care for injuries or illnesses without requiring prior approval.

However, if your physician believes the guidelines best than recommend a varying treatment, they may request a deviation. The physician must prove the treatment is reasonable and medically necessary. Before the physician begins treatment, they must make the variation request. It would be best to have a knowledgeable Workers’ Compensation attorney negotiating with you with the medical provider.

Workers’ Compensation law approves expanding medical providers authorized to treat New York injured workers. This law allows more healthcare providers to treat more injured workers.

Licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, and occupational and physical therapists may become board-authorized providers as of January 1, 2020. Any provider treating injured Workers’ Compensation employees must become board-authorized. As a result, the physician can not treat and bill using their physician authorization number.

The Workers’ Compensation Board website offers an easy online application process to apply and renew for authorization. In addition, healthcare providers and payers may sign up for the Board’s Medical Portal, allowing the submission of medical information for the Board to view online.

The Board has taken actions to improve the Workers’ Compensation system for providers. It aims to encourage more providers to participate. In addition, the Board implemented new fee schedules with higher reimbursement rates and additional increases for certain specialty provider groups.

The Board has updated the following inpatient and outpatient fee schedules.

  • Compensation for injured workers
  • Enhanced ambulatory patient group
  • EAG fee schedules
  • Podiatry fee schedule
  • Dental fee schedule
  • Private psychiatric hospital fee schedule
  • Durable medical equipment fee schedule, payable fees for out-of-state treatment, and information for each fee schedule

Ground Rule 17 designates enhanced provider reimbursement to increase the number of board-authorized providers in primary care medicine, including family medicine, general practice, and internal medicine specialties. In addition, the Board established a specific modifier, 1D, to provide a 20% reimbursement increase rating codes and services underground Rule 18.

A behavioral health provider enhanced reimbursement specific modifier, 1B, will provide a 20% reimbursement increase for providers with board-assigned rating codes for designated services. Service-built designated providers should use the appropriate modifier if not yet paid by filing an HP-1 form and assigning delegates. The Board can assist in drafting prior authorization requests or pars and then review and submitted by the healthcare provider. In addition, they can prepare escalations to level two medication pars. A drafted escalation to level three receives the attention of the medical director’s office for review. The Board can assist you when responding to ensure the information request draft and submission to the healthcare provider’s decision on unpaid medical bills or Form HP.

The Board’s formulary contains a preferred medication list to prescribe without requiring prior approval. However, a newer medication refill for a patient’s current medication at a lower strength requires a request for non-formulary drugs through the Medical Portal process.

The legislative implementation of the mandated medical treatment guidelines changed healthcare delivery to injured workers, including four evidence-based guidelines involving neck, back, and shoulder injury treatment. In addition, MTGs for the ankle and foot, elbow, hand, wrist, and forearm, including carpal tunnel syndrome, hip, and growth disorders, occupational interstitial lung disease, and occupational or work-related asthma injuries, were added to the guidelines.

The MTGs became updated in September 2021 in New York, including mid and lower back, neck, knee, and shoulder injuries and non-acute pain. In addition, the Board integrated MTGs for post-traumatic stress disorder (PTSD), acute stress disorder, work-related depression, and depressive disorders, formerly referred to as major depressive disorder.

Payers may electronically transmit EOBs/EORs to their XML submission partner for adjudication of the electronic CMS-1500 to acknowledge medical bills within seven business days. However, a payer may reject an electronic bill from the designated XML submission partner if a mandatory field is left blank or the insurer declines to cover the employer. A rejection must occur within seven business days of the date first transmitting the bill by the provider’s XML submission partner or clearinghouse.

Payers must identify all legal and valuation objectives for medical bill payment and submit with EOB/EOR payers for objections within 45 calendar days of medical bill receipt, either paper or digital. In addition, the payer must file objections with the Board.

Providers are encouraged to utilize an XML submission partner when submitting the CMS-1500. However, providers are not required when mandatory submission of the CMS-1500 begins with the use of current medical billing reports, such as the physician’s initial report.

The provider must include on the top of the CMS-1500 form a narrative medical report of the patient’s temporary impairment percentage work status in the causal relationship of the injury. Payers must use the new Form C-8.1B and Form C-8.4 with applicable C arcs for medical bill objections. In addition, payers must provide electronic EOBs to healthcare providers to identify the same CRC as specified on Form C-8.1B or Form C-8.4.

When providers use the medical narrative template, they must attach a narrative report with examination findings, the history of the injury or illness, objective findings based on clinical evaluation, and diagnosis. Instead of using the template, the provider must include patient assessment, plan of care, and the provider’s medical narrative report.

Refer to your state’s Workers’ Compensation Board website or speak with a Workers’ Compensation attorney for additional information.