Susan Sternberg flags double denials
- Susan Sternberg pointed to a New York workers’ compensation prior-authorization problem in which carriers can issue a denial at Level 1 and again at Level 2 before cases reach board review. - In the state’s OnBoard system, denied treatment requests can escalate to the Medical Director’s Office at Level 3, while providers and injured workers may need separate filings to resolve legal issues. - The complaint lands inside a system New York says handled more than 2 million prior-authorization requests, with 8% escalating to Level 3 review. (wcb.ny.gov)
Susan Sternberg highlighted a New York workers’ compensation workflow in which a treatment request can be denied twice by a carrier before the state board reviews it. (wcb.ny.gov) (x.com) The system at issue is OnBoard, the New York State Workers’ Compensation Board’s online platform for prior authorization requests, or PARs, for treatment, testing, medication and durable medical equipment. Providers submit the request online, and the case is routed to the insurer or claim administrator for review. (wcb.ny.gov 1) (wcb.ny.gov 2) New York’s training materials show a multi-step review path. A payer gets a Level 1 review, some requests can move to Level 2, and certain disputes can then be escalated to the Board’s Medical Director’s Office for Level 3 review. (wcb.ny.gov 1) (wcb.ny.gov 2) That structure helps explain the “double denial” complaint. If a carrier rejects the same PAR in both internal review stages before Level 3, providers face repeated denials before the board’s medical office weighs in. (wcb.ny.gov 1) (wcb.ny.gov 2) The board’s own guidance says a Medical Director’s Office determination on an escalated denial is final on medical necessity. But that decision still does not settle separate legal disputes such as causal relationship or whether a body part is established in the claim. (content.govdelivery.com) That means one treatment fight can split into two tracks: a medical-necessity review inside OnBoard and a separate “Request for Further Action” filing on unresolved legal issues. The board updated Form RFA-2 in December 2023 to align that process with PAR denials. (content.govdelivery.com) New York has presented OnBoard as a scale success. The board said in November 2024 that the platform had processed 2,018,639 PAR submissions since May 2022, and only 8% needed escalation to Level 3 review. (content.govdelivery.com) (wcb.ny.gov) The same update said 92% of PARs were resolved without Level 3 review within 30 days or less, depending on the required response time for that PAR type. The board also said it had made more than 75 enhancements to the PAR process since launch. (content.govdelivery.com) One of those enhancements was aimed at duplicate filings, but for unpaid-medical-bill submissions, not PAR denials. The board said it had added a feature preventing duplicate HP-1 submissions while continuing to refine prior-authorization processing. (content.govdelivery.com) Sternberg’s complaint points to a narrower problem than whether OnBoard exists or handles volume. It points to what happens when the same treatment request hits repeated carrier denials before the board can issue a medical-necessity ruling. (x.com) (wcb.ny.gov)
