The Role of Medical Providers in Workers’ Compensation

Medical providers have a critical role in the New York state Workers’ Compensation system and the process of becoming board-authorized providers. Workers’ Compensation allows employees with work-related illnesses or injuries benefits.

What is Workers’ Compensation?

Workers’ Compensation is a type of no-fault insurance that provides coverage for work-related accidents, injuries, and illnesses. In addition, Workers’ Compensation covers occupational diseases. Finally, it covers medical treatment expenses directly from their employment, wage replacement, and protection for employers and employees.

The employer must provide Workers’ Compensation coverage by purchasing insurance. In addition, employers must not require eligible employees to contribute to the cost of coverage. Therefore, employees are entitled to Workers’ Compensation. Insurers must report incidents to the Workers’ Compensation Board.

Employees may file a claim up to two years after the incident except for claims related to the World Trade Center, but it is not mandatory. The claim becomes payable once the employer or insurance carrier agrees the illness or injury is work-related. However, a Workers’ Compensation law judge will decide if a claim is payable if the employer or insurance carrier files a dispute.

Who requires Workers’ Compensation insurance?

All profit businesses with employees or if the Workers’ Compensation Board considers employees require insurance coverage. The Board includes workers, such as day laborers, leased and borrowed staff, volunteers, part-time workers, family members, and subcontractors.

However, most nonprofit organizations require Workers’ Compensation coverage for employees with domestic workers, home, or healthcare aids who live in the house and work at least 40 hours weekly. If the worker spends time sleeping within the home, count those hours toward the 40 hours.

The New York state Workers’ Compensation Board ensures the employer maintains the mandatory insurance. In addition, the Board receives copies of all claim documents and performs dispute hearings before a law judge when necessary. The Workers’ Compensation Board requires board-authorized providers who administer essential medical care, document treatment, provide additional details, and undergo provider-specific training.

Physicians, chiropractors, podiatrists, and psychologists may obtain authorization to treat patients for many years. However, licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, and occupational and physical therapists may now obtain authorization under the new law to modernize and improve Workers’ Compensation, healthcare options, and patient availability.

As a result, the New York state Workers’ Compensation system expects to bring thousands of new providers. Providers may comment on the causal relationship between the injury, subsequent disability, or death. However, the medical opinion must indicate sufficient probability due to the cause of injury and be supported rationally.

In addition, providers may comment on the diagnosis, proper treatment, Permian, and permanent partial disability schedule. A percentage of the loss of wage earning capacity determines a non-scheduled loss of use. A provider can receive additional training on impairment guidelines for determining a scheduled loss of use.

A provider may also comment on the claimant’s ability to work and the extent or degree of disability, including temporary partial, or total disability.

A percentage expresses the disability, such as 25% for mild, 33.3% for mild to moderate, 50% for moderate, 66.67% for moderate to marked, and 75% for marked. A temporary partial disability states the claimant has temporarily lost some ability to work and earn full wages. However, a claimant exhibits temporary total disability when they can not work and earn wages in any position. Disability is a 100% loss for a temporary total disability.

Healthcare providers must complete and submit medical reports to the New York state Workers’ Compensation Board, insurance carrier, the claimant’s attorney, or licensed representative if available. The Board utilizes the CMS-1500 form. Medical providers must attach a medical narrative report to the CMS-1500 form. However, providers must complete XML form submission registration on the Board’s website before CMS-1500 and narrative report submission.

However, medical providers may not bill patients, and grounds for revocation of Board authorization. Instead, providers should submit medical bills to the insurance carrier or use a self-insured employer form, A-9, directly. For example, a provider may search for an employer’s Workers’ Compensation insurance carrier on the website. The provider must submit bills within 90 days of the last day of the month of rendering services. Hospitals are allowed 120 days from the last day of rendering services to submit bills.

Providers may ask patients to sign a form online to notify the patient they are responsible for medical costs if the Board rejects compensation. All submitted documents are evident in the Workers’ Compensation case, testimony, and depositions.

Medical providers may provide testimony and depositions within the Workers’ Compensation system. In addition, physicians, chiropractors, podiatrists, psychologists, nurse practitioners, and licensed clinical social workers may need to testify or provide depositions. Board-authorized providers receive reimbursement for services according to the medical fee schedules, available to purchase through Optum.

Each provider and service type authorized provider will have fee schedules. Licensed clinical social workers and psychiatric nurse practitioners must become aware that once authorized and treating patients with work-related mental stress claims. They must present medical evidence of the stressful experience.

Who may experience work-related stress?

Providers who experience work-related extraordinary stress include first responders, emergency police officers, firefighters, EMTs, paramedics, certified emergency medical providers, emergency dispatchers, and other similar roles.

However, an employee does not qualify for Workers’ Compensation benefits if filing a mental stress claim. But consequential psychological injury may apply if the employee’s stress occurs as a lawful personnel decision implicating the employer’s disciplinary work evaluation, job transfer, or termination.

Consequential psychological injuries include depression or post-traumatic stress disorder (PTSD) due to an initial injury or illness. Therefore, the provider must show that the natural consequences of the initial physical injury caused a psychological injury.

For example, an employee cannot work for several months due to a work-related back injury causing depression. The employee’s depression must have developed as a direct result of the back injury. As a result, the employee can not perform daily living activities or work responsibilities. Then the new provider authorization process requires medical providers to apply for authorization through the Board’s Medical Portal on their website.

A provider must register, request access to the Medical Portal, and receive user credentials as part of the authorization process. In addition, the provider must complete all required training before submitting Board authorization and complete the online authorization application within one session.

The provider must have the following information available before beginning the authorization application:

  • First, middle, and last name
  • Date of birth
  • Mailing address
  • Mailing practice address
  • New York state license number
  • The authorized and registered supervising physician’s name, authorization, and license number
  • Copies of Board certifications, if applicable
    • For example, an American Board of Medical Specialities, the American Osteopathic Association, or the National Certification Commission for Acupuncture and Oriental Medicine
  • Disciplinary information
  • Workers’ Compensation Board prior authorization number, if applicable
  • Curriculum vitae or resume
  • Physician assistants must provide their national provider identifier, email address, and a list of languages spoken

A provider can not treat Workers’ Compensation claimants until they receive application approval and the Board permits authorization. A physician assistant must submit the authorization application to the county’s medical society where the physician’s primary office resides, the particular county medical society, or the New York state osteopathic medical association.

The Workers’ Compensation Board will consider the county medical society’s recommendation when providing authorization approval for osteopathic physicians.

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

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