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Medical Provider Networks Overview and issues after one year. Kathy Dervin, M.P.H. Medical Unit/Managed Care Program DWC Educational Conference March 1/2 and March 6/7, 2006. Options for medical care in workers’ compensation. Pre-designation LC §4600/CCR § 9783 (new) 30 day control

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Medical provider networks overview and issues after one year

Medical Provider NetworksOverview and issues after one year

Kathy Dervin, M.P.H.

Medical Unit/Managed Care Program

DWC Educational Conference

March 1/2 and March 6/7, 2006

Options for medical care in workers compensation
Options for medical care in workers’ compensation

  • Pre-designation LC §4600/CCR § 9783 (new)

  • 30 day control

  • Labor-Management agreements (“carve-outs)

    • Permits 24 hour-like integration pilots

  • Health Care Organizations

  • Medical Provider Networks

  • Non-directed care (employee choice)

Medical provider networks overview
Medical Provider Networks: Overview

  • Labor Code §4616

  • 8 Calif. Code of Regulations §9767.1 et seq

    • Final regs in adopted Sept 15, 2005

  • 8 Calif. Code of Regulations §9768 for Independent Medical Review

Permanent regulations see summary of all changes on website or regs
Permanent regulationsSee summary of all changes on website or regs

  • Requires a 30 day notice period

  • Defines “regional provider listing”

  • Applicant must confirm that a contract ( with providers) exists to provide treatment to injured workers in wc system

  • Requires MPN to have at least 3 physicians of each specialty….within the access standards

  • Clarifies MPN obligations when employee lives or works outside service area

Permanent regulations cont d
Permanent regulations (cont’d)

  • Clarifies when regional listing must be provided or made available

  • Makes transfer of care and continuity of care language more comparable in:

    • Definitions of conditions

    • Time frames for conditions

    • Dispute resolution process through LC §4062

Who can set up a mpn
Who can set up a MPN?

  • Self-insured employers, group self-insurers

  • Insurers

  • Joint Powers Authorities

  • State of Calif.

  • CIGA, Self-insured Security Fund

First year of mpn activity nov 1 2004 through oct 31 2005
First year of MPN activityNov 1, 2004 through Oct. 31, 2005

  • 1103 applications received including:

    • 13 ineligible

    • 37 withdrawn by applicant

  • 968 MPNs approved

Types of mpn applicants nov 1 04 through oct 31 05
Types of MPN applicantsNov 1, 04 through Oct 31, 05

  • % (n)

  • Insurer 60.5% (637)

  • Self-insured Employer 35.7% (376)

  • Joint Powers Authority 3.3 % (35)

  • State 0.3% (3)

  • Group self insured employer 0.2% (2)

  • CIGA 0.1% (1)

  • How many payers and employees do mpns cover after one year
    How many payers and employees do MPNs cover after one year?

    • Using an estimate of % of payers who have established a MPN and their market share,

    • ~ 55 % of employees are now covered by a payer that has established a MPN between Jan 1, 2005 and Nov 1, 2005

    • Implementation of coverage unclear

    • Status of transfer of care into MPNs unclear

    • Rapid adoption and implementation of MPNs

    Networks being used in mpns
    Networks being used in MPNs

    • First Health

    • Prudent Buyer (Blue Cross of Calif.)

    • Kaiser

    • CorVel

    • Concentra

    • Interplan

    • Medex

    • Wellcomp, Status Care, others

    • Customized networks

    Mpn access standards
    MPN access standards

    • Geographic access standards

      • Primary care -- 15 miles

      • Hospital -- 15 miles

      • Specialist/occupational health -- 30 miles

    • Time to appointment

      • 1st visit within 3 business days

      • Specialist appt. within 20 days

    • Rural area –alternative standards permissible

    • Out of network standards

    Access to care in mpns issues
    Access to care in MPNs: Issues

    • List not given promptly, not given at all

    • List not accessible on website

    • List inadequate (full regional list not provided)

    • Providers on list won’t take injured worker as patient:

      • Doesn’t take WC

      • Not taking new WC patients

      • Won’t take post-operative case

      • Won’t take “difficult” case w/ complications

    Employee notification
    Employee notification

    • Once MPN is approved notice is required:

      • Initial notice - 30 days before effective date

      • Time of injury notice

      • Notice of IMR at request for 3rd opinion when diagnosis or treatment is being contested

      • Choice of physician and provider directory

      • All notices must be in English and Spanish

      • Don’t send Spanish speakers info on MPN in English !

    Mpn provider listings
    MPN provider listings

    • Provider listings must be available to covered employees

    • Web version must be accessible (w/any passwords being used)

    • Hard copies must ALSO be readily available

    • Regional listing

    • Full listing, upon request

    What is a regional listing
    What is a regional listing?

    • A listing of ALL MPN providers (PTPs and specialists) within the 15 mile/30 mile radius, or a larger radius if needed to ensure at least 3 specialists of each kind

    • A county listing of all MPN providers where the employee lives or works

    • This listing must be readily available to covered employees

    • Web listings, hard copies, in Spanish

    Medical disputes over treatment in mpns
    Medical disputes over treatment in MPNs

    • UR approval or denial  LC §4062

    • Disagreement over diagnosis or treatment

      • Change physicians within MPN is first option

      • Second opinion

      • Third opinion

      • Independent Medical Review

    Second and third opinion imr
    Second and third opinion  IMR

    • Employee tells MPN they want a second opinion

    • MPN makes sure employee has provider list to choose from, chooses a physician

    • MPN contacts 2nd opinion physician, sends medical records

    • 2nd opinion physician writes report

    • If agrees with patient, care is provided within MPN

    • If agrees with PTP, patient can go on to 3rd opinion

    Second and third opinion imr1
    Second and third opinion  IMR

    • 3rd opinion repeats process. At time of 3rd opinion, MPN must notify patient about IMR

    • If patient disagrees with 3rd opinion, fills out a IMR request form (to be provided by MPN/claims adjuster and sent to DWC Medical Unit)

    • IMR reviewer reviews all report

      • Supports patient-care care be given outside MPN

      • Supports 3 previous physicians-care continues in MPN

    Medical provider networks overview and issues after one year

    • DWC Medical Unit has recruited IMR physicians

    • Process set forth in Title 8 CCR §9768

    • No valid IMR request has yet been received

    Transfer of care policy
    Transfer of Care Policy

    • Written transfer of care policy to guide this process

    • Will you transfer open claims?

      • Is the treating physician in your network already? If yes, no need to transfer

      • Which cases will you transfer? none, some, all—how many open claims do you have—needs planning

      • Must follow the policy set forth in 9767.9 to determine whether and when care can be transferred

    Transfer of care process
    Transfer of care process

    • Steps:

      • 1) Determine whether the injured employee has a condition allowing them to stay with current doctor

        • Acute

        • Serious/chronic

        • Surgery authorized and set within 180 days of MPN start

        • Terminal illness

      • 2) Send a letter informing the employee of the determination (in Spanish if employee speaks Spanish)

    Transfer of care process cont d
    Transfer of care process (cont’d)

    • 3) If employee disagrees with determination made by payer, employees asks treating physician to write a report on condition. Physician must submit report within 20 days.

    • 4) If payer contests physician report, and wants to proceed with transfer, dispute must be resolved under 4062.

    • 5) While dispute is being settled treatment employee continues treatment with PT. PTP continues to control referrals until transfer is complete.


    • MPNs should have a mechanism to monitor :

      • Access (geographic, temporal-time to appt)

        • MPN must help employees having trouble getting an appointment

      • Provider choices, providers taking new patients

      • Employees not having info they need

      • Provider network listings

      • Out of area care, referrals out of network

      • Complaints and problems

    Mpn complaint process
    MPN Complaint Process

    • Complaints from workers, providers, attnys, insured employers

    • DWC gathers info to ID compliance issues or problem area

    • DWC contacts MPN liaison person

    • MPN asked to investigate and report to DWC

    • If problem exists:

      • Correct for individual case

      • See that MPN procedures are correct and followed

    Ongoing mpn compliance
    Ongoing MPN compliance

    • Approved MPNs must continue to meet all of the standards they were approved under or may face suspension/revocation of approval

    • Material modifications—when certain changes are made MPN must submit a material modification to DWC for approval

    • For plans approved under the emergency regulations any material modification post Sept 15, 2005 triggers a complete update to the permanent regulations

    Mpn resources on dwc website
    MPN resources on DWC website

    • Regulations

    • MPN coverpage, material modification page

    • Frequently asked questions for applicants and MPNs

    • Summary of permanent reg changes

    • Sample MPN employee notice (updated)

    • List of all approved MPNs

    • Dear provider letter on how to get into MPN