Relates to workers' access to treatment

• Democratic15
• Republican1

◆ The sponsor's argument

Why Nathalia Fernandez says this is needed

This bill works to restore the overall goal of the Workers' Compensation Law, which is the provision of a swift and sure source of benefits to injured employees or the dependents of deceased employees. Cr.osby v. Workers' Comp, 57 N.Y.2d 305, 313 (N.Y. 1982). First, this legislation raises the pre-authorization limit of $1,000 to $1,500 to account for the increased prices of medical care and to help eliminate unnecessary delays in the provision of routine tests and procedures. Second, this bill makes clear that the Board's "list of pre-authorized procedures" or Medical Treatment Guidelines (MTGs) is to be used only as a list of treatments not requiring carrier approval, not as a means to automatically deny any procedures not on the list. Based on industry data, at this time, only treatments within the MTGs are receiving authorization, which others consistently get denied as not medically necessary despite the authorization request having come from a medical provider. This has led to a drastic decrease in doctors willing to participate in the Workers' Compensation system - providers often will not perform a pre-authorized procedure without receiving authorization for fear that the carrier will still deny the bills. The legislative history supporting the adoption of the list of preau- thorized procedures in 2007 indicates that its purpose was to reduce impediments to prompt diagnostic and treatment measures. The sooner injured workers receive their treatment, the sooner they can return to work. Unfortunately, that has not been the reality as implemented by the Board. Due to the complexity of the MTGs and the authorization system, many injured workers and their providers experience undue delays and have stopped working with Workers' Compensation altogether, transferring the costs to private insurance. Finally, this bill restores claimants' right for payment of services by out-of-network providers the right to which was upheld by our court system and then eliminated by the Workers' Compensation Board. The Court in Rivera v. North Central Bronx Hospital, 101 A.D.3d 1304 (3dDept. 2012) determined that even if an injured worker failed to use the diagnostic testing network, the carrier would pay the out-of-network provider at the negotiated network rate pursuant to the language and intent of the law. However, the Workers' Compensation Board has adopted regulations which contravene this holding. These regulations preclude any payment to any out-of-network provider, making it more difficult for injured workers to obtain testing. This legislation allows injured work- ers to obtain treatment in a timely manner, while also reducing costs of treatment by requiring out-of-network providers to accept payment at the carrier's negotiated network rate. Notably, this was the concern of the dissenting judges in Matter of KioKigin v. New York State Workers' Compensation Board, 24 NY3d 459 (2014) where a split Court of Appeals upheld the Board's creation of the MTGs. In the dissent, Judge Rivera noted, "to the extent the Board's regulations establish a variance scheme that predetermines that all treatment not included on the preau- thorized list of services is presumptively not medically necessary, it imposed a burden on Kigin and other claimants inconsistent with the statute's language and underlying purpose.

This is the sponsor's own case for the bill, quoted from their memorandum. It is not Agora's description of what the bill does.