Workers' Compensation Committee Update
July 1, 2010

Staff Contact: Maggie Moree

Rulemaking on Implementing Medical Treatment Guidelines Released

The WCB published rulemaking to implement the Medical Treatment Guidelines in the June 30, 2010 State Register. A summary of the proposed rulemaking can be found here; the full text of the rules are here. The Medical Treatment Guidelines, for which these implementation rules will apply, have been amended since their initial submission to the WCB in December 2007, and can be found here. The MTGs will be "incorporated by reference" into the rulemaking so you will not find them restated within the rulemaking. There is a 45 day comment period, which closes August 16, 2010.

There is a significant amount of process proposed in these rules; there will be new forms, new deadlines to incorporate within your internal review systems, and, changes which reflect in at least one instance a deviation from the statute. Very few comments offered by The Business Council on an earlier draft were incorporated into the published rulemaking.

Some highlights include:

• A two-part definition of maximum medical improvement (see §324.1(d)).
• A new interpretation of the statute allowing procedures in excess of $1,000 to be deemed preauthorized except for 12 specifically enumerated procedures (see §324.2(d)(1) and (2).
• A process to request a variance from the Medical Treatment Guidelines which places the burden for the request on the treating medical provider; requires that "all questions" on the variance form be "completely" answered; and that the variance include, among other things, an explanation on why alternatives under the MTGs are not sufficient; the variance process includes timeframes and steps for responding to the request; and procedures to handle denials of a variance through an expedited hearing process (see §324.3).
• Proposed changes to existing regulation §325-1.3 to require all medical reports to be filed on the most recent version of the forms, to be "fully completed", and to extend from 45 days to 90 days, when a medical report is to be filed subsequent to the 48 hours and 15 day filings. This current 45 day timeframe was, recent as 2006, a 22 day timeframe. Please read this carefully as concerns have been raised as to how this timeframe aligns with the MTGs and whether this proposed 90 day reporting timeframe is inconsistent with a care regimen for a claimant who has not reached MMI.
• An opt-in "prior approval" process which would permit treating medical providers to request of carriers which have opted-in to secure prior approval for a proposed treatment plan consistent with the Medical Treatment Guidelines.
• Proposed changes to existing regulation §325-1.4 which proposes a more detailed process by which authorization for special services including PT and OT are to be handled.

Workers' Comp Committee To Meet July 14; Discuss Draft Regs & Identify Next Steps

Now that the long-awaited MTGs are close to going live, the Workers' Comp Committee will meet on Wednesday, July 14, to discuss this proposed rulemaking and develop formal feedback to be submitted to the WCB on the draft regulations. The meeting will start at 11 am; lunch will be served. More details and registration can be found here.

Presenters at the meeting will include Pam Caggianelli from Bausch & Lomb, and a member of the team that developed the initial Medical Treatment Guidelines; Linda Hull from Upstate WorkComp on how TPAs might incorporate the MTGs to improve efficiency and derive cost savings; and Jim Hall from Liberty Mutual on his company's learnings from the MTG pilot initiated by the Board and why the opt-in prior approval process might be worth pursuing.

This will then wrap into a conversation led by Steve Scotti of ConEd, on common observations on the draft rulemaking and concerns we will formally comment on prior to the comment period closing date of August 16, 2010.

While not ideal given the meeting dynamics, if you wish to participate in this meeting via phone, please reach out to me directly.

A Picture's Worth a Thousand Words....

As our members are on the front lines of the workers' compensation system, what might read as "okay" to me, when viewed by you through the practical lens of how things work "in the real world", may cast a different light on the subject. I hope to see you on the 14th; if you are not able to join us please feel free to share with me any concerns you have.

My initial read through these led me to this: