It is a fact of life in the world of New York State Workers’ Compensation that getting medication is not as easy as your everyday trip to the pharmacy to pick up a prescription. One of the main reasons for this is the number of parties involved, and the regulatory structure under which those parties do business.
We tend to think of the medications which we take as a private business between our doctors and ourselves. Although we are aware that our private health insurance has a say in what will and will not be paid for, the Doctor is well aware of those particular restrictions, and will prescribe accordingly, keeping the prescription machine flowing smoothly enough that being able to obtain a prescription is relatively easy.
For compensation claimants, there are not only more parties that stand between you and your medication, there is the additional regulatory filter of the New York State Medical Treatment Guidelines. These are guidelines that all parties involved must adhere to.
For the Workers’ Compensation claimant it may be better to think of a prescription as a request, rather than Doctor’s Orders. It is a request that has to pass through all parties involved in order to be granted.
Here is an overview of the general process:
- Claimant sees the doctor and medications are prescribed.
The claimant has a medical visit with a doctor who prescribes medication that is related to the treatment of his injury. The prescribing of the medication or the continued use of the medication should be clearly spelled out by the treating physician in the medical narrative report. All medications should be written down at every medical visit. Do not hesitate to let your doctor know this.
- The prescription is not enough.
Although your pharmacy will take your prescription and enter it into their system as a request, a prescription is not adequate documentation for the compensation insurance carrier to authorize the release of that medication to you. When you are first injured, you may get a one-time fill of medication which will be paid when the claim is accepted, or will be charged back to private insurance if the claim is not accepted. However, once past that first-time fill your prescriptions will go through the normal channels. From that point forward, the prescription will not be filled without clear medical evidence of the need for the medication. A prescription, therefore, is just a request without evidence or explanation.
- The Third Party
There is a third party pharmacy administrator that stands between the pharmacy and the compensation insurance carrier. The third party administrator basically verifies all your prescription information and passes your prescription request on to the insurance carrier for authorization.
- The Insurance Adjuster/Case Manager.
The insurance adjuster is the one who will receive the request from the third party administrator and authorize your prescription. Ongoing prescriptions that are clearly recommended by the guidelines will be the easiest to pass through the system. Prescriptions that fall outside the guidelines will require a secondary review, and will normally be rejected without a clear medical explanation of their necessity in the doctor’s medical reports. Often a separate Letter of Medical Necessity will be required.
- Adjusters take vacations.
Compensation claimants need to be aware that insurance adjusters go on vacation, and “substitute” case managers are not always readily available, causing a delay in getting prescriptions. Contact your attorney with any issues.
- Nurse Case Manager, Utilization Review.
Any prescription usage under New York Workers’ Compensation is subject to review by a medical professional, usually Nurse Case Managers. This is especially true with “chronic” users of medication who have been taking medications for extended periods (generally anything longer than 6 months). Any ongoing use of opiates and other narcotic medications is closely monitored. Requests falling outside the guidelines that are clearly indicated as necessary may be subject to Utilization Review.
- Durable medical equipment requests (braces, canes, wheelchairs).
Durable medical equipment is treated as just another prescription, and is subject to the same processes and guidelines as any other medication.
- Contact your legal representative.
If you are represented in your worker’s compensation claim, contact your attorney’s office with any prescription medication issues – Do not contact the insurance carrier directly.
John M. Bellinger
This entry was written by John Bellinger, who is part of the Worker’s Compensation team at MCV Law.
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