Fee Caps and Schedules for Personal Injury Claims

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Workplace Injuries in New York

Workplace injuries are more common than you would believe. In fact, in New York, almost 14,000 people filed a claim for workers’ compensation in 2018. This equates to roughly $493,006,235 being paid to victims of workplace injuries or their families. Beyond that, however, workplace accidents can have devastating, long-term effects on you, your family, and your future.

With Accident Help Zone, we know how scary any type of accident can be for all those involved. In order to make the best decision, you need to have the most up to date information that may impact a personal injury claim. Below, we discuss several of the proposed fee caps and schedules that might affect a personal injury claim.

Workers’ Compensation: What It Means for Personal Injuries

In New York City, the Worker’s Compensation Board (WCB) is responsible for administering the Workers Compensation Law (WCL). Charged with protecting the rights of both employees and employers alike, the WCB strives to ensure benefits and compliance with all laws is prompt, fair, and appropriate. One of their primary responsibilities includes creating, maintaining and enforcing the WCB Medical Fee Schedule.

According to Ins. Law §5108; 11 NYCRR 68.1(a), the WCB Fee Schedule applies to no-fault insurance claims as well, with assumed appropriate modifications. This is important to note as it means the regulations administered towards a workers’ compensation claim will also likely apply to other types of personal injury claims as well. As an example, this can include no-fault automobile accidents.

Because of this, it is important for those affected by workplace accidents or any other type of personal injuries to be aware of the regulations being published by the WCB.

Proposed Changes That May Affect Your Case

In June 2018, the WCB published their proposed changes to the WCB Medical Fee Schedule for public review. Comments were received and addressed in October 2018. Responses and revised proposed changes were published at that time. Some of the most important changes that may affect workers’ compensation and personal injury claims alike are below.

Physical Therapy Limits:

Physical therapy treatments are currently limited to 12 visits or 45 days after the first treatment per the Physical Medicine Section, Ground Rule 2 of the current WCB Medical Fee Schedule. To go beyond these limitations, a certification from a physician was required proving that physical therapy was necessary to recovery.

Surprisingly, the WCB has proposed changing this limit to 12 visits or 180 days after the first treatment. While this may appear gracious, the caveat will be that a physician’s certification will no longer justify care beyond this.

In addition, as with the physical therapy limits, chiropractic care will be limited to 12 visits or 180 days after the first treatment, regardless of whether you need continued care or not.

Daily Treatment Limits:

At present, the current Fee Schedule limits reimbursement for physical therapy services to eight Relative Value Units, or RVUs, per day. (RVUs are actually based on the amount of work required to treat you. A surgeon’s RVU will be higher than that of a physician.) The current language is often contested as it does not specify whether these 8 RVUs per day is capped per person or for each type of care received.

The newly proposed changes will increase this cap to 12 RVUs per day. However, it will now specify that the RVUs are limited to 12, regardless of whether you saw two different providers or not. (Chiropractic care is included in this overarching 12 RVUs per day.) When an initial evaluation and treatment occur on the same day, this limit will be increased from 13.5 to 18 RVUs. Follow-up evaluations and treatments that occur on the same day will see a similar increase, from 11 to 15 RVUs.

Chiropractic Services:

Current chiropractic care is addressed by the Chiropractic Fee Schedule. A new proposed Ground Rule 10 of this section is perhaps one of the mostly hotly contested. As it is being proposed, this new rule appears to prohibit chiropractors from using billing codes that are not listed within the Chiropractic Fee Schedule. This can include services they are licensed and qualified to provide, such as manipulation under anesthesia (MUA).

This may be where workers’ compensation and other types of personal injuries vary. In 2010, the WCB responded to public comments via the New York State Register stating that Medical Treatment Guidelines (MTGs) will not apply to no-fault claims. If this holds true, the new limitation on chiropractic services will not affect other personal injury claims.

Conversion Factors:

Regional conversion factors in all locations across New York will see an increase. An overall average of five percent can be expected, but many areas may see even higher increases. Some practitioners argue, however, that these increases will be offset by the other limitations noted above.

Know Your Rights

Understanding your rights after being injured is essential to receiving the compensation you deserve. If you would like to know more about what to do if you have suffered a workplace accident or personal injury, visit the Accident Help Zone today.