Medication and Transportation (M&T) Reimbursement in New York: A Primer

New York Workers’ Compensation Law (WCL) dictates that an injured worker is entitled to reimbursement for certain expenses relating to an established compensable claim. WCL Section 13(a) provides that an employer is obligated to provide an injured employee with such medical, surgical, or other attendance or treatment as the nature of the injury or the process for recovery may require. In kind, courts have ruled that transportation costs incurred in connection with medical treatment are compensable if reasonable, and that the statute should be interpreted …

Continue Reading

Treatment Authorization Requests: Ensuring Proper Compliance with 12 NYCRR 325-1.4

Workers’ Compensation Law Section 13 establishes the obligation of the employer to “promptly provide for an injured employee such medical surgical, optometric or other attendance or treatment… for such period as the nature of the injury or the process of recovery may require.”

When requesting authorization for treatment, the provider submits a Board form titled, “Attending Doctor’s Request for Authorization and Insurer’s Response.”  The Board code for the form is shortened to C-4AUTH. Unlike a variance request, a request for authorization in a C-4AUTH is …

Continue Reading

Expanded Provider Legislation; Implications for Insurance Carriers

As part of Gov. Cuomo’s 2019-20 executive budget, a new law was passed expanding the types of medical providers that can apply to be authorized to treat injured workers under the New York State Workers’ Compensation System. The law will be effective January 1, 2020.

Prior to the legislation taking effect, only physicians, chiropractors, podiatrists, and psychologists could apply to be board-authorized to treat injured workers while nurse practitioners (NPs), physician assistants (PAs), occupational therapists, physical therapists and licensed clinical social workers (LCSWs) could only …

Continue Reading

The Biggest Loser: How to Handle Requests for Causally Related Bariatric Bypass Surgery

Under the New York State workers’ compensation law, an employer or carrier “shall promptly provide for an injured employee such medical, surgical, optometric or other attendance of treatment . . . for such period as the nature of the injury or the process of recovery may require.”  This is a pretty general requirement, but it opens the door to a new question: what happens when an injured worker requires back surgery, but is not a candidate because he or she is overweight? They have two …

Continue Reading

Raising Self-Limitation on Reduced Earnings: A New Approach

How many times has your attorney heard this whispered after raising labor market attachment:  “Just go get any job out there and they’ll pay you the difference – any job will do.” If you work two hours a week, you’re attached and owed reduced earnings. This scenario came up during a recent litigation on the issue of labor market attachment and entitlement to awards. In that case, the claimant’s attorney maintained that the claimant was “working for someone he met online,” taking care of their …

Continue Reading

One Missing IME, Too Many

I recently attended a hearing that was scheduled pursuant to claimant’s RFA-1, requesting reinstatement of awards. You’re probably wondering, why were awards suspended in the first place? Because claimant had missed three scheduled independent medical examinations (IMEs)! She also did not have current medical evidence of a further causally related disability at the last hearing. The prior notice of decision read wonderfully, “suspension is effective until such time that the claimant produces up to date evidence of disability and indicates a willingness to attend the …

Continue Reading

Untimely Notice of Controversy or Pre-Hearing Conference Statement? Why Carriers Should Not Give Up Hope on a Disallowance

Where a carrier has elected to controvert a claim, the Workers’ Compensation Law in New York sets forth a strict timeframe for filing a denial and initial pleadings. Section 25(2)(b) provides that once a claim has been indexed against an employer, the carrier must file a notice of controversy with the Chair within 25 days. Failure to file the notice of controversy within the prescribed 25-day time limit shall bar the employer and its insurance carrier from asserting multiple defenses, including that the claimant was …

Continue Reading