Navigating New York State Medical Treatment Guidelines and PARs: 2024

Navigating New York State Medical Treatment Guidelines and PARs: 2024

Established in 2010 by the NYS Workers’ Comp Board, the Medical Treatment Guidelines (MTG) specify a single standard of medical care for the treatment of injured workers. A more formalized and complex medical treatment process than most other states, the Medical Treatment Guidelines continue to evolve with the rapidly shifting industry.

With strict deadlines and steep penalties, it’s crucial to have the most up-to-date information about forms, deadlines and updates to the guidelines. Viscardi is here to help -- as one of New York State’s experts in PAR review and MTG consulting, we’ve compiled the most important information you need to know to navigate NYS MTG and PARs in 2024.

Medical Treatment Guidelines

The Medical Treatment Guidelines are an evidenced based protocol for the most common workplace injuries. Per the NYS WCB, “The MTGs are the standard of care for treating individuals with work-related injuries and illnesses in New York State and are based on the best available medical evidence and the consensus of experienced medical professionals.”

Prior Authorization Requests

Prior Authorization Requests (PARs) are requests for authorization of a treatment prior to the treatment being delivered. The NYS WCB defines a PAR as “a request by an injured worker's health care provider to obtain prior approval from the payer (e.g., insurance carrier) to cover the costs associated with a specific treatment under workers' compensation insurance.”

Purpose Of The NYS Medical Treatment Guidelines

The NYS MTGs provide a playbook for how certain injuries should be treated and what is and isn’t pre-authorized by the carrier. Standardizing care provides a host of benefits for all parties. The NYS MTGs:

Expedite quality care for injured workers
Improve the medical outcomes for injured worker
Get injured workers back to work more quickly
Reduce disputes over treatment issues between carriers/self-insureds and the medical providers
Increase timely payments to medical providers
Reduce overall system costs

NY WC MTG: What’s Covered?

Since their adoption in 2010, the Workers’ Compensation Board has added additional injury sites to the Treatment Guidelines beyond the initial back, neck, shoulder and knee injuries. The following body parts are included in the Medical Treatment Guidelines:

Knee
Mid and Low Back
Neck
Shoulder
Non-Acute Pain
Ankle and Foot Disorders
Elbow Injuries
Hand, Wrist and Forearm Injuries (including Carpal Tunnel Syndrome)
Hip and Groin Disorders
Occupational Interstitial Lung Disease
Occupational/Work-Related Asthma
Post-Traumatic Stress Disorder and Acute Stress Disorder
Work-Related Depression and Depressive Disorders
Eye Disorders
Traumatic Brain Injury
Complex Regional Pain Syndrome

Out of State (OOS) Treatment Requirements

Out-of-state providers have access to submit requests through OnBoard for New York State claims.

Prior Authorization Requests: What You Need To Know

PARs are managed via the WCB’s electronic dashboard, known as OnBoard. It’s important to note that any treatment variation from the standards of care set forth in the Medical Treatment Guidelines must be requested by a provider via a Prior Authorization Request.

Here at Viscardi, our medical professionals review thousands of PARs a year for Carriers and Self-Insured Employers. We thoroughly evaluate each claim and its history, determining compensability (eligibility for compensation) and medical necessity.

There are currently seven PAR types:

Medication: The request used for prescribing non-formulary medications. It replaces the Drug Formulary Prior Authorization application. Insurers must respond within four calendar days.
MTG Confirmation: The request confirms that the proposed treatment or test is based on the correct utilization of the MTGs. Insurers must respond within eight business days. Health care providers do not have to submit MTG Confirmations, but a response from payers is mandatory.
MTG Variance: Used to request treatments and tests that vary from what’s included in the MTGs. Insurers must respond within 15 calendar days, in accordance with General Construction Law, of receiving the request. If they decide to request an independent medical examination (IME), the insurer must notify both the healthcare provider and the Chair within five business days of the decision and respond within 30 calendar days, in accordance with General Construction Law, of receiving the request.
Non-MTG Over $1,000: Used to request treatment or tests costing more than $1,000 with no applicable MTGs. The insurer must respond within 30 calendar days in accordance with General Construction Law.
Non-MTG Under or =$1,000: Used to request treatment or tests costing $1,000 or less with no applicable MTGs. The insurer must respond within eight business days.
MTG Special Services: Used to request special services. The insurer must respond within the same timeframe as the MTG Variance outlined above.
Durable Medical Equipment: Used to request durable medical equipment not listed on the Durable Medical Equipment Fee Schedule or one that is listed on the schedule but requires prior authorization. The insurer must respond within four calendar days in accordance with General Construction Law.

Per the WCB, “General Construction Law (GCL) 25a states: ‘When any period of time, computed from a certain day, within which or after which or before which an act is authorized or required to be done, ends on a Saturday, Sunday or a public holiday, such act may be done on the next succeeding business day…’”

With response time under 2.5 days, Viscardi ensures that each PAR request is responded to accurately and timely--avoiding costly penalties and fines. If you’d like to learn more about Viscardi’s Compliance and Variance Review Services, contact us today for a free consult.

For more information on the New York State Medical Treatment Guidelines, visit this link.