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Medical Director’s Office and Bureau of Health Management

Medical Director’s Office and Bureau of Health Management. Board Presentation Jaime Szeinuk, MD Elain Sobol Berger, MD, JD July, 19, 2011 . Medical Director’s Office (MDO). WCB had been without physician staff since 1996 and without a Medical Director since 1998.

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Medical Director’s Office and Bureau of Health Management

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  1. Medical Director’s Office and Bureau of Health Management Board Presentation Jaime Szeinuk, MD Elain Sobol Berger, MD, JD July, 19, 2011

  2. Medical Director’s Office (MDO) • WCB had been without physician staff since 1996 and without a Medical Director since 1998. • With the development and implementation of the Medical Treatment Guidelines, the WCB recognized the need for strong medical representation and re-established the Medical Director’s Office.

  3. Medical Director’s Office

  4. Medical Director’s Office • June 2009, the Board announced the appointment of Steven Levin, M.D. as Interim Medical Director. • April 2010, the Board appointed Elain Sobol Berger M.D, J.D., as Associate Medical Director/Senior Policy Advisor. • June 2010, Jaime Szeinuk, M.D. succeeded Dr. Levin.

  5. Medical Director’s Office • Medical Director • Associate Medical Director • Five full-time Registered nurses, three full-time Board employees and two full time contract nurses.

  6. Medical Director’s Office The Medical Director’s Office is responsible for the oversight of all medical issues at the Board including: • Promoting high quality care and outcomes for all injured workers. • Implementing the Medical Treatment Guidelines. • Updating the Medical Treatment Guidelines and developing new guidelines. • Educating and training guideline users statewide. • Oversight Bureau of Health Management (HM).

  7. Medical Director’s OfficeMedical Treatment Guidelines • Responsibilities: Regulatory “Medical arbitrator” defined by regulations as the Medical Director of the Board, the Assistant Medical Director of the Board, or a licensed physician designated by the Chair or his designee • Medical arbitrator role • Review of variance denial (MG-2R) and • Optional prior approval (MG-1R)

  8. Medical Director’s OfficeMedical Treatment Guidelines • Responsibilities: Implementation • Oversee the process for review of incorrect MG-1 and MG-2 forms submitted by carriers/providers or for failure to respond in a timely manner. • Issue EC-70/EC-75 • Assist WC Claims Examiners in review of supporting medical documents, as requested, in anticipation of EC-325.

  9. Medical Director’s OfficeMedical Treatment Guidelines • Responsibilities: Resource • Assist providers, carriers and claimants in understanding MTG. • Outreach to applicable parties when carriers deny authorization for tests and treatments that are in accordance with MTG. • Assist WC staff as needed in understanding medical terminology or review of supporting medical documentation.

  10. Medical Director’s OfficeMedical Treatment Guidelines • Responsibilities: Education • Partner with medical provider associations to develop training programs • Speak at stakeholder meetings and conferences across the state and nationally. • Issue Medical Director’s Bulletins.

  11. Medical Director’s OfficeOther Responsibilities • Impartial Specialists (IS) • Selection of physicians to serve on the Impartial Specialist Panel • Participate in the development of IS regulations • Assistance to WCL Judges • Monthly Judge-MDO educational sessions • Consultations as needed

  12. Medical Director’s OfficeBureau of Health Management

  13. Medical Director’s OfficeOther Responsibilities • HM and MDO Work Together • Coordinate, schedule and preside over Board’s arbitration process • Work with HPA Rating and Licensing Unit in the selection of appropriate IS on a case by case basis

  14. Medical Director’s OfficeHealth Management Unit • Health Provider Administration • Authorization of health care providers, IME, medical bureaus and facilities and IME business entities. • Disputed Bill Unit Section (administrative awards, arbitration process) • Rating and Licensing Section

  15. Medical Director’s OfficeHealth Management Unit • Outreach • Education and customer interaction • PPO Program • Certification and monitoring of PPOs • Medical Fee Development and Management • Establish and annually update fee schedule

  16. Medical Director’s OfficeFuture • Medical Advisory Committee • Development of new guidelines • Next guideline-Chronic Pain Syndromes • Review/update existing guidelines

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