325.000 WORKERS’ COMPENSATION

 (See also Reimbursement, 265.000; Utilization Review 310.000)

325.951        Improving Workers’ Compensation Medical Treatment Guidelines Compliance by Insurers

The Medical Society of the State of New York will urge the Workers’ Compensation Board to ensure that insurance carriers are covering injured workers’ medical care consistent with the Board’s medical treatment guidelines and that various health care providers authorized to provide services under the Workers’ Compensation law are familiar with the Board’s medical treatment guidelines.  (HOD 2021-256)

325.952        Education on Worker’s Compensation Manual and Protocol

The Medical Society of the State of New York will advocate for the Chair of Worker’s Compensation to partner with the MSSNY Worker’s Compensation Committee in the development of a program that would educate physicians on the laws, regulations, documentation and salient portions of the NY Worker’s Compensation protocol so that better care for injured patients can be provided, assisting them in fair and just outcomes.  The Worker’s Compensation insurers should provide funding for the development of a comprehensive multimodality educational program for physicians.  (HOD 2018-268) 

325.953        NYS Worker’s Compensation PPOs

The Medical Society of the State of New York will seek legislative and regulatory changes to eradicate the practice of silent PPOs operating in New York State and require adherence with the accepted fee schedule.  MSSNY will seek amendments to the Worker’s Compensation Law that if the carrier reduces the approved and accepted Worker’s Compensation fee schedule, it must pay punitive damages to the Board and to the physician per day in an amount to support just enforcement.  (HOD 2018-267) 

325.954        Prompt Payment of Worker’s Compensation Testimony Fees

The Medical Society of the State of New York should petition the Chair of the Worker’s Compensation Board to require reimbursement to the physician within 30 days of testimony.  (HOD 2018-266)

325.955        Correcting Workers’ Compensation Board Policy

The Medical Society of the State of New York will seek legislation to allow that payment for services be made by the patient or the patient’s private insurance when the patient and physician agree that additional treatment is necessary to improve impairment beyond the services for which the Carrier’s independent medical exam and the Workers’ Compensation administrative law judge are willing to pay under the Workers’ Compensation Program.

MSSNY will seek legislation to ensure that the decision to deny coverage of care recommended by the treating physician may not be made by non-physician personnel under the Workers’ Compensation Program. (HOD 2017-260) 

325.956        Amendments to Workers’ Compensation Law Section 110-a (Confidentiality of Workers’ Compensation Records)

The Medical Society of the State of New York (MSSNY) will seek appropriate legislation or regulation to modify the Workers’ Compensation Law, Section 110-a, Subsection 1(a), which would allow a physician, or his legal representative, the ability to communicate with a member of the Workers’ Compensation Board in instances when there is apparent fraud committed by a Workers’ Compensation claimant or other important information or irregularities relevant to the case.

The MSSNY will seek legislation or regulation to strengthen NYS Workers’ Compensation Law and reduce potential fraud and abuse by amending Workers’ Compensation Law 110-a Part (h) to enable physicians to report alleged discrepancies or apparent fraudulent activities by patients and allow the Workers’ Compensation Board staff to annotate the WC Case file and alert the Workers’ Compensation Fraud Inspector General. (HOD 2017-258) 

325.957        Arbitrary Deadlines for New York State Workers’ Compensation Peer Review Response

The Medical Society State of New York shall require that if a Workers’ Compensation peer review is requested by either party that the peer review be scheduled at a mutually acceptable time. (HOD 2017-256)

325.958        Physician of Choice in Workers’ Compensation Cases

The Medical Society of the State of New York (MSSNY) will seek a change to Section 13-b of the New York State Workers’ Compensation Law to allow an employee with a Workers’ Compensation related illness or injury, who is requesting a second opinion and/or medically necessary services, the right to obtain an independent evaluation and/or treatment from a physician who does not participate or accept Workers’ Compensation, provided that the patient understands and acknowledges that he/she will not seek reimbursement from the Workers’ Compensation program, or other health insurance plans they may have, and that such understanding between patient and physician is documented appropriately.

The Medical Society of the State of New York (MSSNY) will seek an additional change to the Workers’ Compensation Law to allow a Workers’ Compensation claimant to sign an approved document, such as an Advanced Beneficiary Notification (ABN), which clearly explains that the physician providing the second medical opinion and/or medically necessary services is not a Workers’ Compensation authorized physician, and that the patient has agreed to pay the physician directly, without the expectation of reimbursement or the filing of a Workers’ Compensation or other health insurance claim related to the care provided, and that a physician who evaluates a patient under such an arrangement may not be reported to OPMC for alleged violation of state law and that the recommendation generated from this opinion may not be used in a Workers’ Compensation proceeding. (HOD 2012-266, referred, amended, adopted by Council 1/30/2014; Reaffirmed HOD 2024)

325.959           New York State Workers’ Compensation Board Fee Schedule On Line

MSSNY will petition the New York State Workers’ Compensation Board to study the feasibility of placing the “Official New York Workers’ Compensation Board – Medical Fee Schedule” and associated policies in an on-line environment, accessible to authorized physicians without charge, in order to save costs by helping physicians submit proper fee schedule amounts, and by reducing the number of claims/physician fees that are not deemed to be in accordance with the Workers Compensation fee schedule.  (HOD 2011-260; Reaffirmed HOD 2021)

325.960           Timely Payment for Workers’ Compensation Depositions

MSSNY will seek legislation to ensure timely payment for any physician required to provide a deposition relative to a Workers’ Compensation (WC) case.  This timely payment is to be made within thirty (30) days from the date the deposition is given, regardless of the outcome or the time needed to conclude the WC case with interest due and owing as appropriate.  (HOD 2011-259; Reaffirmed HOD 2021)

325.961           American College of Occupational and Environmental Medicine  Guidelines:  SUNSET HOD 2019 

325.962           Definition of Insurance Network:  SUNSET HOD 2019 

325.963           Elimination of the Workers’ Compensation Fee Schedule:  SUNSET HOD 2019

325.964           Workers’ Compensation Claims Reviews by Qualified Physicians:

MSSNY to seek regulation and/or legislation requiring that claims review for Workers’ Compensation claims be performed only by physicians licensed in the State of New York and engaged in the active practice of medicine in a similar scope of practice in the State of New York.  (HOD 2008-261; Reaffirmed HOD 2018)

325.965           Arbitration Fees:

MSSNY will seek a change in legislation or regulation requiring the carrier to pay for the cost of each arbitration in cases where the arbitration committee increases the reimbursement fees paid to the physician.  (HOD 2008-260; Reaffirmed HOD 2018)

325.966           Workers’ Compensation Coding Manual: SUNSET HOD 2015

325.967           Increase to Workers’ Compensation Fee Schedule: 

In recognizing Workers’ Compensation regional conversion factors have not been increased for at least 10 years, that the Medical Society of the State of New York will aggressively pursue the Chairman of the Workers’ Compensation Board to grant an increase of the conversion factors to compensate for the increase in the costs associated with medical practice; and that MSSNY aggressively pursue increases to the Workers’ Compensation regional conversion factors, on an annual basis, so as to bring Workers’ Compensation reimbursements up to current acceptable levels.  (HOD 2005-267; Modified and Reaffirmed HOD 2015)

325.968           Workers’ Compensation Panels: 

MSSNY continue to work with the Workers’ Compensation Board to encourage the enlistment of physicians to serve on arbitration panels.  (HOD 2004-258; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

325.969           Amendment of the Workers’ Compensation HP-1 Requests for Administrative Award Process:

MSSNY will seek an amendment to the Workers’ Compensation Law stating that for every day on which a carrier ignores or refuses to acknowledge a properly tendered HP-1 Request for Administrative Award, that carrier must pay punitive damages to the Board and to the physician per day in an amount to support significant, productive and viable enforcement.  (HOD 2002-258; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

325.970           Workers’ Compensation Law New Sections 300.37 and 325-1.25: Sunset HOD 2011

325.971           Reducing the Costs of Submitting Workers’ Compensation Claims: Sunset HOD 2011

325.972           Workers’ Compensation C-4 Form:Sunset HOD 2011

325.973           “C” Rated Physicians Performing IMEs: Sunset HOD 2011

325.974           Modification of Workers’ Compensation Law Sections 110A and 32:

MSSNY will seek through legislation, regulation, or whatever means necessary, amendments to the NYS WC Law Sections 110A and 32 regarding the physician’s ability to be listed as a Party in Interest.  (Council 11/2/00; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

325.975           Surgical Ground Rule Number 5: SUNSET HOD 2014

325.976           Clarification in Workers’ Compensation Board Regulations Pertaining to the Performance of Independent Medical Examinations NYS: SUNSET HOD 2014

325.977           Caps for Maximum Medical Improvement Exams (MMIEs)(i.e. AMA-CPT Codes 99455 and 99456: SUNSET HOD 2014

325.978           Timely Processing of Claims: SUNSET HOD 2014

325.979           Additional Workers’ Compensation Billing Codes: SUNSET HOD 2014

325.980           Role of a Physical Therapist in Electrodiagnostic Medicine: SUNSET HOD 2014

325.981           Workers’ Compensation Claims Reimbursement: SUNSET HOD 2014

325.982           Augmentation of Damages in Workers’ Compensation Arbitration Cases:

MSSNY will urge the Workers’ Compensation Board to amend its new streamlined appeals process, requiring that:  (1) If a carrier makes misrepresentations to the Board concerning timely and proper receipt of bills, such misrepresentation be considered an act of bad faith, subjecting the carrier to judgment of treble damages; and  (2) If a carrier fails to comply with a decision of the Board, such failure likewise be considered an act of bad faith, subjecting the carrier to judgment of treble damages.  (HOD 2000-275; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

325.983           Timely Authorizations of Procedures:

MSSNY will work with the appropriate agencies to require health care plans to provide adequate staffing/personnel to support the volume of incoming requests for authorizations via telephone in a timely fashion so that the waiting time for answering said calls does not exceed 5 to 10 minutes; MSSNY will work with the appropriate state agencies to require health care plans to accept requests for authorizations by electronic transmission in lieu of telephone requests, and MSSNY will work with the appropriate agencies to ensure that the response time to requests for authorization submitted via FAX not exceed 1 (one) business day.  (HOD 2000-259; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

325.984           Increase in Workers’ Compensation Arbitration Fees: SUNSET HOD 2014

325.985            Timely Authorizations:

MSSNY will urge the New York State Department of Insurance and the New York State Workers Compensation Board to require insurance companies to provide a mechanism for authorizing requests for medical or surgical services in a timely fashion and that such an approval mechanism be available 24 hours a day, seven days a week.  A response to a requested authorization will be returned within 24 hours for in-hospital care and 7 days for outpatient care.  (HOD 1999-272; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

325.986           Hearing Outcomes in Workers’ Compensation Cases:

MSSNY will urge the New York State Workers’ Compensation Board to enforce its current regulation that deems the physician as “an interested party,” and requires the concurrent provision of notices of dates and time of pending hearings to physicians, claimants and representatives, as well as outcomes of any hearing of the Board within 15 days.  (HOD 1999-270; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

325.987           Receipt of Bill in Workers’ Compensation Cases: SUNSET HOD 2014

325.988           Repeal Of Increased Fees For Workers’ Compensation Arbitration: SUNSET HOD 2014

325.989           Treating Physician Is A Party At Interest: SUNSET HOD 2014

325.990           Payment Of Interest To Physicians By Health Insurers For Claims Exceeding 30 Days: SUNSET HOD 2014

325.991           AMA Guide to the Evaluation of Permanent Impairment: (Sunset HOD 2016)

325.992           Work Hardening Program Ground Rules and Medical Fee Schedule: SUNSET HOD 2014

325.993           Prescription of Lenses: SUNSET HOD 2014

325.994           Billing for Interpretation of Plain Film X-Ray Examinations Performed on Emergency Department Patients Covered by Worker’s Compensation During “Off Hours: SUNSET HOD 2014

325.995           Uniform Fee Schedule in Workers’ Compensation/No-Fault Cases: SUNSET HOD 2014

325.996           Medical Equipment and Supplies, Payment for: Sunset HOD 2011

325.997           Differential Payment Based on Specialty Board Certification and Scope of Practice: SUNSET HOD 2014

325.998           Physician Assistants, Payments for Services Under the Workers’ Compensation Program: SUNSET HOD 2014

325.999           Fee Negotiations: 

At the request of the Chairman of the Workers Compensation Board, representatives of the Medical Society of the State of New York are authorized to provide input where feasible and when the situation arises, into the establishment of fees under Workers’ Compensation Law and to negotiate a fixed fee schedule.  MSSNY representatives are not restricted to the usual and customary concept. (HOD 1983-13; Reaffirmed HOD 2013; Reaffirmed HOD 2023)