Health and Safety

Pain in Neck – Medical Treatment Guidelines Aren’t Working, Critics Charge

Pain in Neck – Medical Treatment Guidelines Aren’t Working, Critics Charge

October 18, 2012
By Joe Maniscalco

In 2010, the New York State Workers’ Compensation Board adopted a new set of Medical Treatment Guidelines intended to improve the speed and quality of care delivered to injured workers, while also cutting down on unnecessary or otherwise dubious treatments. But after two years of implementation, critics say that the rules meant to help men and women injured on the job, are actually hurting them by delaying treatment and even discouraging physicians from offering necessary care.

“They did several things that may be all well and good, but are not practical mechanisms of delivering treatment,” Workers’ Compensation attorney John C. Merlino says. “In essence, what I think the guidelines are doing is creating an obstacle.”

As an example, Merlino – who specializes in construction site accidents and union disability benefits for the law firm of Dinkes & Schwitzer – points to an injured client who has been trying to get the green light for an operation he filed for well over six months ago.

“This has multiple negative effects,” Merlino says. “In the meantime, it’s draining Workers’ Compensation, because if workers were able to get surgery quicker, they could also get off of Workers Compensation sooner.”

Workers’ Compensation Board officials maintain that the changes made to the system in 2010 actually return a majority of claimants back to work faster by pre-authorizing all by 13 procedures and removing delays often associated with seeking prior approval from insurance companies.

But that’s not the experience physicians like interventional pain management specialist Dr. Eugene Liu have had since 2010.

“I have strong feelings about this,” Dr. Liu says. “I don’t think they [Medical Treatment Guidelines] necessarily work. The guidelines are supposed to clarify things and make the care more streamlined without delays in the authorization process. But the bottom line is that in practice everybody reads these things differently.”

According to Dr. Liu, the responses he’s gotten for claims submitted to insurance carriers since the new Medical Treatment Guidelines have gone into effect “has been all over the map” with varying determinations sometimes being made within the same entity “depending on who you talk to.”

“Mostly they just don’t want to pay,” Dr. Liu says. “Their favorite phrase is: ‘Does not meet the burden of proof.’ But you follow the guidelines to a tee – and somehow they read it, and still say, ‘This is not what the guidelines say.'”
The new Medical Treatment Guidelines apply to work-related injuries sustained to the neck, back, shoulder and knee.

NYS Workers’ Compensation Board Executive Director Jeffrey Fenster argues that doctors who are treating patients appropriately are being paid faster than they were prior to the new Medical Treatment Guidelines being put into place.

“Unfortunately, some providers in our system have a long and well documented history of providing inappropriate care to the detriment of injured workers,” Fenster says.  “Under the guidelines, where providers have continued to treat inappropriately payment will and should be denied.”

Critics maintain that the new Medical Treatment Guidelines are actually deterring qualified physicians from legitimately offering help to injured people on Workers’ Compensation because of the obstacles they so often face when seeking renumeration.

“Some people do not want to take the risk, so they just don’t do it,” Dr. Liu says. “They’re still sending out the requests, not getting anywhere, and holding up the treatment.”

More injured workers receiving physical therapy and chiropractic care are also discovering that, after a certain point, the treatments they had been receiving in order to keep working, are no longer being covered under Workers’ Compensation.

The Workers’ Compensation Board says that before the new Medical Treatment Guidelines were instituted, physical therapy, chiropractic treatment and steroid injections were all sources of “substantial abuse.” The new rules now limit the courses of those treatments, and require variances for the extension of care beyond recommended allowances.

Merlino acknowledges that one of the aims of the new Medical Treatment Guidelines may have been to reduce fraudulent claims – but insists the way that they have been implemented  has largely been inappropriate.

“It doesn’t make sense,” Merlino says. “It just wasn’t done properly.”

Nevertheless, more changes are coming. Last year, a medical advisory committee began developing chronic pain guidelines that will supplement existing recommendations and can also be utilized as a national model. New Medical Treatment Guidelines involving carpal tunnel syndrome, meanwhile, are expected to be adopted in 2013.

October 19, 2012

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