Medical Guidelines

medical-guidelines

The Variance Process as put forth in the 2010 and 2012 New York Workers’ Compensation Board Medical Treatment Guidelines do not address the realities facing the Injured Workers’ of New York. Of course, if you get hurt at work in NYC you should consult a Bronx Workers Compensation lawyer, a Queens Workers Compensation Lawyer, a New York Workers Compensation lawyer, Staten Island Workers Compensation Lawyer or a Brooklyn Workers Compensation lawyer, or if on Long Island, a Long Island Workers Compensation lawyer. If you consult an attorney at Harris Ugalde & Rzonca, LLP, you can speak to a lawyer about this in either our Queens, Brooklyn or Bronx office. For injuries to the knees, shoulders, back and neck, medical treatment is authorized post-accident per the 2012 Medical Treatment Guidelines. The Workers’ Compensation Law dictates the care given to injured workers.

According to the Guidelines, (1) Medical care for workers’ compensation injuries to the neck, low back, mid back, shoulder, and knee must be provided in a manner “consistent with the MTG.” This is the standard for doctors and health care providers to follow. (2) “Consistent with the MTG” means that care is provided within the criteria and based upon a correct application of the MTG. What is “within the criteria” and “a correct application” is left open for the WCB’s WC Judges to interpret. While this may seem open-ended the general consensus from the Board and our experience in going to hearings is that the injured worker is given 3 months of accident treatment such as physical therapy and chiropractic care.

Anything beyond these three months are generally not considered approved by the guidelines. If the claimant undergoes surgery to the knee, shoulder, back and neck, then again the general consensus is the claimant is entitled to treatment for 3 months post-surgical. Again anything beyond these three months are generally not considered approved by the guidelines. A person however, is not a guideline but a living thing. People heal on their own time in many instances. What, however, does an injured worker do, when he or she is in need of continued treatment beyond these 3 months. To attempt to deal with this eventuality, the Board has implemented the Variance Process. The Variance Process states that the treating provider must file a form called an MG-1 for one procedure or modality, or an MG-2 for multiple procedures or modalities, for any treatment outside the guidelines that they feel is necessary. The carrier is therefore placed in an advantageous position by this process. Basically, it means that all care rendered is deemed to be unauthorized until an action by the medical provider. Therefore, the burden is on the medical provider to meet the guidelines for a Variance in order to treat the claimant. Per the Workers Compensation Law, the medical provider requesting the variance has the burden of proof to show that the treatment requested is appropriate and medically necessary for the claimant. N.Y.C.R.R. Section 324.3(a)(2). The attending doctor requesting the variance must provide:

  • the basis for the opinion that the specified treatment or test is appropriate and is medically necessary;
  • a statement that the claimant agrees to the proposed medical care;
  • an explanation why alternatives contained within the Guidelines are not appropriate or sufficient; and
  • any signs or symptoms which failed to improve with treatment provided in accordance with the Guidelines; or the objective improvements made by particular treatment and the expected improvements with more of the same treatment. See N.Y.C.R.R. 324.3(a)(3).

On the surface, it may seem not that difficult to obtain treatment as long as the Variance Procedure is followed. However, in practice, at the Hearings we attend for Queens Workers Compensation, Bronx Workers Compensation or Brooklyn workers compensation injured workers’ it is nearly impossible to meet the criteria of the Variance Process. Unfortunately, the realities of running a efficient Medical office act as barriers to complying with the Variance process. On each visit, the medical provider must take time out of his or her schedule to create a medical necessity letter that details exactly why the claimant’s treatment is medically necessary. Often this a tedious process which is left to the carrier to decide whether the procedure is medically necessary. In order to not pay extra for care for the claimant, the carrier has a strong impetus to deny all statements of medical necessity pending a decision by the board. If this requirement is somehow overcome, the medical provider must then consult with the claimant to see if the claimant agrees to the proposed medical treatment. Oftentimes, when you are hurt at work nyc, the injured person may not understand why the treatment is being requested. Therefore there may be a delay in obtaining the very necessary treatment being requested. With regard to alternatives to the treatment being renders may fail, there are only so many treatments to be considered for injuries to a person’s neck, back, shoulders and knees. Therefore suggesting alternatives to the tried and true methods of physical therapy and chiropractic manipulation would likely prove difficult for a sprain and strain of a back or neck. With regard to the objective gains the injured worker expects to make by the proposed treatment, we argue that this again does not take into account the struggles of the injured worker. Sometimes, a person is simply in pain and needs care to deal with this pain. A person with a serious sprain and strain with positive diagnostic tests may be working with pain in order to put food on his or her table and continue to work. We argue that the Variance Process does not adequately address the realities of the injured worker and need serious revision in order to provide more effective treatment for the injured people of New York. It is always a good idea to consult a Bronx Workers Compensation attorney, a Queens Workers Compensation attorney, a New York Workers Compensation attorney, Staten Island Workers Compensation attorney or a Brooklyn Workers Compensation attorney, or if on Long Island, a Long Island Workers Compensation attorney. If you speak Polish, we have a Polish Workers Compensation attorney. If you speak Spanish, we have a Spanish workers compensation attorney.