WC BOARD SUSPENDS USE OF CONTROVERSIAL MEDICAL REPORT FORM

Monday, February 1st, 2010

In response to a growing health care access problem for injured workers in the greater Rochester area, New York State Workers’ Compensation Board (WCB) Chair Robert Beloten this week suspended the requirement that the use of any of the C-4 series of forms, whether those mandated in 2009 or previous versions, be utilized in the six-county region surrounding Rochester. According to the WCB release, “authorized physicians, podiatrists, chiropractors and psychologists in the Provider Shortage Area may submit a CMS-1500 with a detailed narrative report or office notes in lieu of one of the prescribed C-4 forms.”

Since other medical providers across other counties in New York State have continued to express concerns regarding the implementation of these forms into their practices, WCB Chair Beloten has also rescinded statewide the requirement that physicians treating injured workers use the newly expanded (2009) family of C-4 forms, and instead may use the previous version of the C-4 form, which is far simpler, but still requires that some version of the C-4 form be used. According the WCB release, “In all areas of the State, the Board will enforce payment in accordance with the Workers’ Compensation Law and regulation regardless of the version of the C-4 form used to report examinations, services and/or treatments rendered by providers.”

MSSNY member Dr. Jeffrey Kahn, a Syracuse physiatrist who chairs the MSSNY Committee on Workers’ Compensation and No Fault Insurance, has led an effort since 2007 when the WCB first disclosed its intent to implement these new C-4 forms, to convince the WCB to significantly alter its proposed plans regarding the use of any new C-4 forms. Dr. Kahn and other physician leaders informed the WCB that the use of these new forms would impose significant new administrative burdens on physicians across New York State, and potentially cause some physicians to leave the Workers’ Compensation program altogether. We are pleased that some of the MSSNY recommended changes were incorporated, as well as the WCB’s integration of Dr. Kahn’s recommendations to offer both paper and electronic versions of the C-4 forms with a centralized fax submission system. Nevertheless, both MSSNY and the New York State Society of Orthopedic Surgeons (NYSSOS) have continued to object to the usage of these forms, even after their implementation, due to the hardship to many medical practices regarding both the time and costs forced upon medical providers who have attempted to remain in compliance.

A related concern is the fact that physician reimbursement for treating injured workers has not been increased since 1994. In several recent meetings between the WCB with Dr. Kahn and MSSNY, the WCB has acknowledged the need for an increase in these fees to bring them to a level consistent with the type of care provided as well as the financial burdens placed upon physician practices due to the new C-4 forms. The Board and MSSNY are working with the Governor’s office to achieve such an increase. The New York State AFL-CIO has also advocated for such an increase. MSSNY will continue to advocate to assure that a fair and reasonable fee schedule increase for treating injured workers is implemented as soon as possible.

To read the full Board release, click here.

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Temporary Change in Medical Reporting Requirements

Friday, January 29th, 2010

Authorized Provider Shortage in Rochester Area;

Temporary Change in Medical Reporting Requirements

Date: January 26, 2010

Physicians, with limited exceptions, podiatrists, chiropractors and psychologists must be authorized by the Chair in order to treat workers’ compensation claimants. Physical and occupational therapists may treat claimants either under the direct supervision of or upon referral by a physician. Nurses and other health providers may only treat workers’ compensation claimants under the direct supervision of an authorized physician.

It is important that injured workers have access to authorized providers in order to receive necessary care and treatment. Further, it is also important that injured workers receive such care and treatment as quickly as possible in order to ensure the best and speediest recovery. The faster an injured worker is treated and recovers, the faster such worker can return to work. In order to receive treatment quickly there must be authorized providers available to treat injured workers.

In the past two years a number of physicians have voluntarily surrendered their authorizations to treat workers’ compensation claimants. A large number of these physicians are located in the Rochester area of the state resulting in a temporary shortage of authorized providers to treat injured workers. Specifically, the temporary shortage of authorized physicians exists in the counties of Monroe, Livingston, Steuben, Allegheny, Wyoming and Ontario.

When these providers surrendered their authorizations, injured workers treated by them were forced to find a new provider. In addition, newly-injured workers had to find other providers to treat them. This has resulted in an increased demand for the services of the providers who have retained their authorization to treat injured workers. This demand has placed a burden on authorized providers to timely complete and submit the prescribed medical report forms. Delays in the submission of medical reports cause delays in the receipt of benefits by injured workers.

I find that there is a temporary shortage of authorized providers in the counties of Monroe, Livingston, Steuben, Allegheny, Wyoming and Ontario. These counties shall collectively be deemed the Provider Temporary Shortage Area.

In order to address this situation, in the Provider Temporary Shortage Area I am including in the list of prescribed medical report forms the CMS-1500 (or HCFA-1500) form with detailed narrative reports or office notes. Authorized physicians, podiatrists, chiropractors and psychologists in the Provider Shortage Area may submit a CMS-1500 with a detailed narrative report or office notes in lieu of one of the prescribed C-4 forms. If a CMS-1500 is submitted without the detailed narrative report or office notes, it is not a prescribed form. A narrative report or office notes are considered detailed when they contain the necessary information in sufficient detail so the insurance carrier can properly process the submission.

Further, the statement in Subject Number 046-301R dated March 23, 2009, that the Board will not enforce payment for examinations, services and/or treatments provided after April 1, 2009, if they are not reported using the correct new C-4 report is rescinded Statewide. In all areas of the State, the Board will enforce payment in accordance with the Workers’ Compensation Law and regulation regardless of the version of the C-4 form used to report examinations, services and/or treatments rendered by providers. For providers located within the Provider Temporary Shortage Area, the Board will also enforce payment in accordance with the Workers’ Compensation Law and regulations if a CMS-1500 (or HCFA-1500) with detailed narrative report or office notes is used to report examinations, services and/or treatment for the duration of the shortage.

Insurance carriers may not refuse to pay bills for failure to file one of the prescribed C-4 forms; however, they may raise an objection to the bill if the service is not sufficiently detailed in the office notes or narrative reports.

The Provider Temporary Shortage Area designation and addition to the prescribed list of medical report forms takes effect immediately. Once it is determined that the shortage no longer exists the list of prescribed medical report forms will be revised to require use of the C-4 forms.

Any questions regarding these matters should be referred to the Office of General Counsel at 518-486-9564.

Robert E. Beloten
Chair

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WC BOARD SUSPENDS USE OF CONTROVERSIAL MEDICAL REPORT FORM

Temporary Change in Medical Reporting Requirements

Authorized Provider Shortage in Rochester Area;

Temporary Change in Medical Reporting Requirements

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