At the time of the launch of Onboard: Limited Release, stakeholders, health care providers, medical suppliers, insurers, and third-party administrators will be required to submit prior authorization requests for care, as well as a request for decision on unpaid medical bills via the platform. This will also be the trigger date for implementation of the adopted new sections of the New York State Workers’ Compensation Board’s Medical Treatment Guidelines.
The criteria utilized for each of the mental health guideline sections is based on diagnostic and statistical manuals (DSM) forms. These are DSM for mental disorders that were developed by the American Psychiatric Association and are based on multiple criteria necessary to reach a particular diagnosis.
Some initial stand-out language includes the section for post-traumatic stress disorder (PTSD) and acute stress disorder (ASD), which both call for “serious injury” exposure. Additionally, for ASD, there must be nine or more of the symptoms provided for in the five different categories. Care must be taken to assure that the criteria are not associated with another medical condition (i.e., either other psychiatric conditions or physical injuries).
In meeting the criteria for major stress disorder, it is noted not to include symptoms clearly attributable to another medical condition or due distress in social, occupation, or other important areas. Specifically, under section two, it points out that a medical condition itself (i.e., physical injury) is a life stressor. From the DSM-5, in order to reach the diagnosis of major depressive disorder, a patient must meet the first two of the criteria, in addition to at least three others parts of the criteria which remain the same for a two-week period, as well as signifying a change from prior function for the patient. It also notes that a remission can occur when there is a period of three weeks with no more than three of the criteria symptoms remaining.
Additionally, the Medical Treatment Guideline sections for psychological management, pharmacological management, and adjunctive therapies set forth specifics on modalities, doses, and duration to allow for ease of access to recommended care once a diagnosis is made, and when a variance would be required for the specific therapies.
Insurers are recommended to monitor and calendar the implementation date of the OnBoard: Limited Release platform when the Board provides guidance on the launch date. Please consider reaching out to counsel once the new Medical Treatment Guidelines for these mental health conditions are implemented to ensure that you are ready to defend against the diagnosis with the right area of specialty for any expert opinion. There is now a foundation for specific criteria, duration discussions, and additional guidance with the criteria, which may help create a defense against establishing these difficult conditions. Additionally, the standard of care for the conditions, if established, has a foundation to allow for better cost containment, timelines, and the ultimate goal of reaching remission.
If you have any questions about these changes or how they impact your business, please contact: