Ongoing Maintenance Care in New York: Four Things You Need to Know

Supporting an injured worker through his or her recovery follows a specific protocol and process—but what happens when that injured worker isn’t getting better?

In New York, the Workers’ Compensation Board has created an Ongoing Maintenance Care (OMC) program to support injured workers with chronic pain who have plateaued in their recovery. It’s an enormously valuable service for people who need continual care. From a medical management perspective, it can also be a tricky process to navigate.

Here, we outline the four most important things you need to know about New York’s Ongoing Maintenance Care program to ensure you’re meeting the criteria outlined by MTG.

  1. The injured worker must have reached maximum medical improvement (MMI)
    Despite what many people believe, maintenance care is applicable to both working and non-working employees. It is for patients who have been found to be at MMI—the point in an injured worker’s recovery where further improvement is unlikely—and have been classified with a permanent disability. A patient can be at her MMI and can return to work, or not, based on her job description and MD release.

  2. Maintenance visit documentation is critical to solidifying ongoing maintenance care
    Three important criteria must be met and documented:

    • The injured worker must participate in a self-management program that they develop in partnership with the provider

    • The injured worker must have worsening symptoms despite participating in the self-management program

    • The injured worker must have specific functional goals for the maintenance treatment that are “identified, measured and met.”

    According to the Workers’ Compensation Board, “The provider must establish, with documentation in the medical record, that the previous treatment maintained functional status and that, without treatment, functional status deteriorated. The need for ongoing maintenance treatment must be evaluated periodically by progressively longer trials of therapeutic withdrawal of maintenance treatment. Within a year, and annually thereafter, a trial without the maintenance treatment should be instituted. If deterioration in functional ability is documented during the therapeutic withdrawal, reinstatement of the ongoing maintenance care program may be acceptable.”

    Often, adjusters and claim owners are ill-prepared and lack the time to ensure that when maintenance visits are provided that the provider has met the above requirements in his/her documentation. If it is not met, the adjuster or claim owner has the right to file a C8.1 to deny payment.

  3. Only one provider can develop a course of treatment for a particular body part
    Injured workers are more often than not treated by several medical specialists: doctors, chiropractors, physical therapists, occupational therapists and more. However, under the MTG, only one provider can create a course of treatment for a particular body part.

  4. If both the provider and injured worker meet the requirements of MTG no variances are required
    In 2013, the Workers’ Compensation Board released new MTGs which eliminated the need for a variance to provide ongoing maintenance. No variances are currently required if both provider and patient meet the requirements of the MTG.

The Workers’ Compensation Board has a fairly comprehensive rundown on its Ongoing Maintenance Care program here. If you have any questions specific to your case or know you need some OMC experts to help navigate the process, shoot us an email. We’d be happy to help.

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