New York State is to resume In-person hearings at the Workers' Compensation Board on or after 10/7/24! Although the WCB has decided to reopen its hearing points for In-person hearings, it will continue to allow virtual attendance. In-person attendance is strictly voluntary. It remains to be seen how the reopening will be laid out across the state. It is also an unknown regarding whether claimants and attorneys will choose to attend hearings in-person. 

New York State workers' compensation hearings have been held exclusively via the Board's virtual hearing system since the onset of the COVID-19 pandemic in March 2020. 

Rule 325-1.26

·         Treatment by chiropractors, acupuncturists, physical therapists, and occupational therapists must be done in person.

·         Treatment by physicians, podiatrists, nurse practitioners, and P.A.s

o    First exam in person

o    For treatment within three months of injury date, every third exam in person

o    For treatment more than three months from injury date, in person exam required every three months unless claimant at permanent MMI

§  If claimant at MMI, at least one in person exam per year required

·         Treatment by Psychologists and Licensed Clinical Social Workers

o    Remote visits allowed under certain circumstances

o    For treatment more than three months after the injury date, in person exam is required every three months unless claimant at MMI

o    IMEs may be done by telehealth when all parties consent and IME is not opining on permanency

Board Announcement

In mid-2024, the Board will start issuing notices of indexing for all cases where the file contains a C-3 or FROI-00 and a medical report which triggers the carrier’s obligation to file a Notice of Controversy

The minimum compensation rate was increased as a result of legislation signed by Governor Hochul (S1161-A/A2034-A). The new law provides that the minimum compensation rate in workers’ compensation claims will increase according to the following schedule:

- 01/01/2024—$275

- 01/01/2025—$325

- 07/01/2026—increased to one-fifth of the state average weekly wage

The new minimum rate law will significantly change the manner in which employers and carriers handle claims involving lower wage workers. In 2024, those claimants with an average weekly wage of $412.50 or lower will have both total and partial disability rates of $275 per week. Under these circumstances, there is little value in an independent medical examination to address degree of disability, as there is no way to modify the rate. Additionally, those claimants subject to the minimum compensation rate will have little financial incentive to return to work given that they will receive their full after-tax wages regardless of their disability. 

Maximum Compensation Rate: Effective 7/1/23 the maximum weekly indemnity rate under WCL §15(6) increased to $1,145.43 based on annual indexing of the state average weekly wage. 

Board Offices Remain Closed to the Public.  Hearings in New York workers’ compensation matters continue on a virtual basis only, with all parties, attorneys and witnesses appearing via computer and mobile phone connections from their offices or homes employing the Board’s statewide Virtual Hearing System. The Board closed all of its offices and hearing sites to the public on 3/17/20 as a public safety measure in response to the COVID-19 pandemic. The Board recently advised that it plans to reopen hearing sites to the public again, but as of this writing it still has not provided a date when in-person hearings will resume.

Certain other changes to Board procedure instituted during the COVID-19 pandemic remain. For example, the requirement for original handwritten signatures on several Board forms was suspended as a result of the pandemic and remains in effect.

New York Issues Permanent Telehealth Regulations

On 7/11/23, new telehealth regulations went into effect in New York State. These regulations outline the circumstances in which injured workers in New York may receive telehealth services from a health care provider and the types of providers authorized to provide telehealth services. Notably missing from the proposed regulations are details on the method and manner by which employers and carriers may object to an injured worker’s use of telehealth services in circumstances where it may not be warranted.

The new permanent telehealth regulations are in Section 325-1.26 of Title 12 of the NYCRR. Telehealth was at one time limited to rural or remote communities; however, since the COVID-19 pandemic, telehealth has been more widely embraced. The New York Workers’ Compensation Board adopted emergency regulations during the pandemic to allow for expanded use of telehealth. The new permanent regulations do not simply make the old emergency regulations permanent. The emergency regulations provided more latitude to providers in the use of telehealth services. The new regulations limit the use of telehealth depending on the type of provider and the phase of the claimant’s injury.

Certain providers may not provide telehealth services at all. These include: chiropractors, acupuncturists, physical therapists, and occupational therapists. This makes sense, as the treatment modalities offered by these providers are “hands-on” and, presently, the best clinical practice for these providers involve in-person visits.

Physicians, podiatrists, psychologists, nurse practitioners, physician assistants, and licensed clinical social workers are permitted to provide telehealth services to claimant via two-way audio or audio and visual communication subject to limitations depending on the care provided and the phase of injury. Additionally, those providers using telehealth must be able to meet the claimant at the provider's office within a reasonable travel time and distance from the claimant's residence.

The regulations divide the phases of a claimant’s injury into acute/sub-acute, chronic, and maximum medical improvement (“MMI”). The acute/sub-acute phase of injury is defined as within the first three months following the date of injury. Use of telehealth during the acute/sub-acute phase is at the clinical discretion of the treating provider, except that at least every third visit must be in person. 

After three months from the date of injury is considered the “chronic” phase of injury under these regulations. During the chronic phase of injury, the provider is permitted to use telehealth at their discretion except that there must be an in person visit at least every three months or until the provider feels that the claimant has reached maximum medical improvement.

Once the treating provider feels that the claimant has reached MMI, further telehealth visits may be at the provider’s clinical discretion except that there must be an in-person visit by the providers at least annually.

Telehealth treatment for mental health conditions by psychologists and licensed clinical social workers are treated differently under these regulations. For mental health treatment, the only limitation is that the telehealth treatment be medically appropriate and permitted under the Medical Treatment Guidelines. Mental health treatment is not subject to the phase of injury limitations noted above for physicians, podiatrists, nurse practitioners, and physician assistants. The regulations state that remote mental health treatment should be limited to those situations where there is "no benefit" to in-person services. Additionally, treating mental health professional needs to document the reason for the use of remote services for each telehealth visit. There is no indication in the regulations as to what constitutes an adequate reason for use of telehealth services for mental health treatment.

The regulations define “medically appropriate for telehealth” as where an in-person physical examination of the claimant is not needed to assess the claimant’s clinical status, need for further diagnostic testing, appropriate treatment, or to determine causal relationship of level of disability. This section of the regulations (12 NYCRR 325-1.26(c)(1) and (2)) goes on to provide factors or parameters where an in-person physical examination may or may not be necessary but note that such factors should not be used by carriers or employers as the basis for a denial of services. This implies that employers and carriers have no recourse if the provider is using telehealth in a situation where it is not warranted. Providers are not obligated to provide an analysis or refer to any one factor in support of using telehealth over an in-person exam.

Moreover, the factors that address where no in-person physical exam may be necessary, 12 NYCRR 325-1.26(c)(1)(i)–(viii), are vague. For example, 12 NYCRR 325-1.26(c)(1)(i), provides that telehealth could be appropriate for management of chronic conditions where the provider has previously conducted a medically appropriate and comprehensive in person assessment of the patient and condition and is fully familiar with the applicable medical history; however, factor (i) does not provide a timeframe for when this prior in person exam might have occurred or if the specific provider conducted this exam, i.e., another treatment provider in the same office conducted the in-person exam. Also, factor (viii) provides a catch-all scenario as prescribed in the Medical Treatment Guidelines or other related Board communications; however, it is unclear what this would mean in terms of supporting a telehealth visit over that of in person.

12 NYCRR 325-1.26(c)(2)(i)-(ix) provides for the factors that would indicate the necessity of a physical exam. Notably, factor (vi) focuses on an in-person exam to address degree of disability or range of motion. Degree of disability is a basic component of medical evidence submitted to the Board. Claimants in the temporary phase of disability are required to submit medical evidence regarding degree of disability every 90 days to maintain their entitlement to benefits. It is unclear how telehealth could be useful as factor (vi) acknowledges that degree of disability and range of motion should be addressed only in an in-person exam. Further, factor (ix) provides that although causal relationship should be addressed in an in-person exam, the provider could in theory ascribe causal relationship if the provider is able to articulate in the medical record why an in-person exam was not necessary to determine causal relationship. Causal relationship is routinely addressed in the acute phase of an injury. 12 NYCRR 325-1.26(c) provides that the absence or existence of these factors should not serve as a basis of a denial by carriers, self-insured employers, or third-party administrators, but causal relationship is a viable defense routinely raised by the carrier, self-insured employers, or third-party administrators. 12 NYCRR 325-1.26(c)(2)(ix) would seem indicate that the provider may now support causal relationship with a lesser burden of proof, i.e., not the physical exam findings, but some other factor in the medical record.

Nothing in the new regulations addresses when and how an employer or carrier might deny telehealth treatment that was rendered inappropriately. This would suggest that employers and carriers have no recourse if the provider is simply opting to use telehealth. Providers are not obligated to provide an analysis or refer to any one factor in support of using telehealth versus an in-person exam.

The Board acknowledged the lack of guidance in an email sent on 7/13/23. That email, entitled “Telehealth Guidance” addressed the proper method for payers to object to treatment via telehealth, in instances where the payer believes the use of telehealth was inappropriate and inconsistent with the regulation. The email provides little relief for employers and carriers who want to ensure that providers are providing telehealth services consistent with the new regulations because the email states that the fact that medical treatment was provided via telehealth cannot be the sole reason for an objection to a medical bill. Rather, the employer or carrier should instead file an RFA-2, check box “K” and request a direction for future in-person visit in accordance with the regulation, and state why the visit should not be performed via telehealth.

Even after filing the request for further action, employers and carriers should not expect much help from the Board. This is because the email also indicated that the Board would not entertain C-8.1 objections from employers and carriers who object to telehealth treatment by providers who were previously directed to provide in-person treatment. Rather, the Board stated that such providers would be subject to “administrative action.”

Only in cases where a chiropractor, acupuncturist, physical therapist, or occupational therapist provides telehealth services would the Board entertain a C-8.1 objection from an employer or carrier. We do not expect that there will be many situations where this comes up.

Finally, the regulations state that Independent Medical Examinations (“IMEs”) may be conducted via telehealth when all parties of interest consent to a telehealth examination and where the IME is not offering an opinion on permanent impairment. This may provide an opportunity for employers and carriers to secure an IME on mental health claims where it is difficult to find a psychiatrist or psychologist in the claimant's home community.

With the permanent implementation of these regulations, telehealth is here to stay. Despite the numerous requirements for providers, there is no enforcement mechanism for employers or carriers to ensure compliance with these regulations. They can only rely on the Board's promise of "administrative action." At a minimum, employers and carriers should update their processes to ensure that any telehealth visit by a chiropractor, acupuncturist, physical therapist, or occupational therapist is objected to with a C-8.1. For other providers who use telehealth inconsistent with the new regulations, employers and carriers can file an RFA-2 and request a direction that the provider provide in-person visits in the future.

Passing of the Torch

Our founding partners, Mark Hamberger and Ronald Weiss, have served on the firm’s Governing Committee, and as Managing Partners in the Buffalo and Rochester offices respectively, since the founding of the firm in 1991. Effective January 1, 2023, Mark and Ron have decided that the time has come to pass the management responsibilities to the next generation. 

Accordingly, the firm created a new Governing Committee, and elected F. Daniel Bowers, Renée Heitger, and Joseph DeCoursey to serve on that committee, effective January 1, 2023 to manage the firm. Dan and Joe will serve as Managing Partners in Buffalo and Rochester respectively.  

Under Mark and Ron’s 31 years of leadership, the firm has grown to become the largest law firm dedicated solely to Workers’ Compensation defense in New York. Mark and Ron will remain with the Firm as Special Counsel, where they will play integral roles in the firm's continued success.

 H&W Saves Client Nearly $60,000 With Fraud Finding and Permanent Bar on Indemnity

Our associate, Victoria Hahn, obtained a WCL §114-a (fraud) finding and secured a permanent disqualification of the claimant's indemnity benefits for our client in a particularly tricky claim that was decided a few weeks ago. The claimant in this case had been out of work since the date of accident in March 2020. Our client's investigator was able to get some limited evidence of the claimant's work activity: a few photos and a 10 second video from an informant showing the claimant working as a carpenter at a job site. During testimony, the claimant alleged that he was just "helping a friend." Unfortunately, the informant was murdered before trial in an unrelated incident, leaving Tori without much of a case. 
 
Undeterred, she subpoenaed the claimant's bank records, which showed large deposits into a business account in the claimant's name, with the claimant listed as the sole signer and authorized user. These records were critical as they proved that the claimant was engaged in substantial work activity while collecting workers' compensation benefits. The Law Judge felt that the video surveillance and photographs were insufficient on their own to establish a fraud finding. However, the Judge found that the bank records completely discredited the claimant's testimony and that the only logical conclusion regarding the deposits noted in the bank records were that they were for services performed by the claimant on behalf of his business. 
 
Given the classification with a permanent partial disability and a 33% loss of wage earning capacity Tori's efforts saved our client nearly $60,000 in workers' compensation payments. For any questions about this case, please contact Tori and if you have a fraud case you would like to us to review, please contact us.