Medical Director’s Office and Bureau of Health Management

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