Medical Provider Medical Provider Networks Networks Kathy Dervin, M.P.H. Kathy Dervin, M.P.H. and Anne Searcy, M.D.and Anne Searcy, M.D.

DWC Educational ConferenceDWC Educational ConferenceFebruary/March, 2005February/March, 2005

Choices for medical care in Choices for medical care in workers’ compensationworkers’ compensation

Pre-designation per LC 4600 Pre-designation per LC 4600 30 day control30 day control Labor-Management agreements Labor-Management agreements

(“carve-outs)(“carve-outs) Permits 24 hour-like integration pilotsPermits 24 hour-like integration pilots

Health Care OrganizationsHealth Care Organizations Medical Provider NetworksMedical Provider Networks Non-directed care (employee choice)Non-directed care (employee choice)

Medical Provider Medical Provider Networks: OverviewNetworks: Overview

Labor Code 4616Labor Code 4616 8 Calif. Code of Regulations 9767.1 et 8 Calif. Code of Regulations 9767.1 et

esq.esq. Emergency regs in effectEmergency regs in effect Final rules under review for adoption Final rules under review for adoption

March 1March 1 9768 rules on Independent Medical 9768 rules on Independent Medical

ReviewReview Effective date of MPNs January 1, 2005Effective date of MPNs January 1, 2005

Who can set up an MPN?Who can set up an MPN?

Self-insured employersSelf-insured employers InsurersInsurers Joint Powers AuthoritiesJoint Powers Authorities State of California (agencies of)State of California (agencies of)

Who can Who can notnot set up an set up an MPN?MPN?

Provider networksProvider networks Insured employersInsured employers TPAsTPAs Clinics or provider groupsClinics or provider groups Medical management/UR companiesMedical management/UR companies

MPN Implementation MPN Implementation ProcessProcess

Application process to DWC (stage we Application process to DWC (stage we are in now)are in now)

Start up of new MPN coverage (just Start up of new MPN coverage (just beginning)beginning)

Expansion of MPNsExpansion of MPNs New injuriesNew injuries Transfer of careTransfer of care

MonitoringMonitoring Evaluation (to be determined)Evaluation (to be determined)

MPN application processMPN application process

Eligible applicant organization Eligible applicant organization submits application to DWCsubmits application to DWC

DWC has 60 days to act on a DWC has 60 days to act on a complete application:complete application: IneligibleIneligible IncompleteIncomplete Deficient Deficient Disapproved Disapproved ApprovedApproved

Standards for MPNsStandards for MPNs Adequate number and type of providers Adequate number and type of providers

to meet the needs of the employer’s to meet the needs of the employer’s common injuries based on type of common injuries based on type of industry and occupationindustry and occupation

Access to specific types of providers Access to specific types of providers ( including those mentioned in LC 3209.3 ( including those mentioned in LC 3209.3 and 3209.5)and 3209.5)

Mix of occupational and non-occupational Mix of occupational and non-occupational providers (goal of 25 % non-occ)providers (goal of 25 % non-occ)

Defined geographic service area and Defined geographic service area and number of employees to be coverednumber of employees to be covered

Standards for MPNsStandards for MPNs

Access standardsAccess standards Primary carePrimary care HospitalHospital Specialist/occupationalSpecialist/occupational

Continuity of care policyContinuity of care policy Transfer of care policyTransfer of care policy Economic profiling policy-if presentEconomic profiling policy-if present

Standards for MPNsStandards for MPNs

Employee NotificationEmployee Notification Choice of physician and provider Choice of physician and provider

directorydirectory Second and third opinion processSecond and third opinion process

Not med-legal, but a treatment second Not med-legal, but a treatment second opinion when dispute over diagnosis or opinion when dispute over diagnosis or treatmenttreatment

Independent Medical Review Independent Medical Review

How to put together a MPN How to put together a MPN applicationapplication

Read regulationsRead regulations Follow regulationsFollow regulations Choose compatible network and Choose compatible network and

partnerspartners Submit Submit completecomplete application to DWC application to DWC Other resources:Other resources:

Frequently Asked Questions on MPNsFrequently Asked Questions on MPNs Sample employee noticeSample employee notice Follow the regulations (did I say this?)Follow the regulations (did I say this?)

Key issues: Employee Key issues: Employee notificationnotification

MPNs are newMPNs are new New things are confusingNew things are confusing They represent a big change in wc They represent a big change in wc

medical care and choice of providermedical care and choice of provider Change can be confusing and Change can be confusing and

unsettling….unsettling….

Which bring us to employee Which bring us to employee notification……..notification……..

Employee notificationEmployee notification Follow the regulations—specifically 9767.12 Follow the regulations—specifically 9767.12

and 9768.9 (IMR notice)and 9768.9 (IMR notice) Before implementation of a MPN, covered Before implementation of a MPN, covered

employees must be given a written notice employees must be given a written notice (English and Spanish)(English and Spanish)

At time of injury, notice must be givenAt time of injury, notice must be given After first visit employee must be told of their After first visit employee must be told of their

right to chose a(nother) physician and how to right to chose a(nother) physician and how to access the MPN provider directory (LC access the MPN provider directory (LC 4616(b))4616(b))

At time of 3At time of 3rdrd opinion request IMR notice must opinion request IMR notice must be givenbe given

Things not to put in your Things not to put in your employee notificationemployee notification

Mandatory forms that are not in the Mandatory forms that are not in the regulationsregulations

New time frames not in the regulationsNew time frames not in the regulations Restrictions on change of physicianRestrictions on change of physician Obligations on covered employees that Obligations on covered employees that

are not in the regulationsare not in the regulations Restrictions on choice of physician Restrictions on choice of physician

(except as allowed on appropriateness) (except as allowed on appropriateness)

Common problems with Common problems with employee notificationsemployee notifications

Employee must use a mandatory form to Employee must use a mandatory form to request 2request 2ndnd or 3 or 3rdrd opinion opinion

Employee must request 2Employee must request 2ndnd or 3 or 3rdrd opinion opinion with 10-20-or any number of dayswith 10-20-or any number of days

Changing wording of regulatory Changing wording of regulatory requirements, time frames set forth in requirements, time frames set forth in regsregs

Not disclosing employee rights in MPNNot disclosing employee rights in MPN Restrictions to provider listingRestrictions to provider listing

Regs allow regional listing but full listing must Regs allow regional listing but full listing must also be made availablealso be made available

So—how many MPNs are So—how many MPNs are there?there?

DWC has received over 600 applications DWC has received over 600 applications since November 1since November 1stst..

80 have been approved as of February 80 have been approved as of February 12th12th List of approvals at www.dir.ca.gov/dwcList of approvals at www.dir.ca.gov/dwc

Many have been disapprovedMany have been disapproved Many are still in the review processMany are still in the review process Many are still coming in—we expect to Many are still coming in—we expect to

review between ~750 and 2000 review between ~750 and 2000 applications applications

Start Up and Start Up and ImplementationImplementation

Once a MPN is approved—notify your Once a MPN is approved—notify your covered employees using your approved covered employees using your approved employee notification materials/lettersemployee notification materials/letters

New Injuries – referral into MPN initial New Injuries – referral into MPN initial providerprovider

MPN contact to perform required MPN contact to perform required functions-make sure information is functions-make sure information is availableavailable

Existing injuries: to transfer or not to Existing injuries: to transfer or not to transfer?transfer?

Transfer of CareTransfer of Care

Written transfer of care policy to guide Written transfer of care policy to guide this processthis process

Will you transfer open claims?Will you transfer open claims? Is the treating physician in your network Is the treating physician in your network

already? If yes, no need to transferalready? If yes, no need to transfer Which cases will you transfer-none, some, all—Which cases will you transfer-none, some, all—

how many open claims do you have—needs how many open claims do you have—needs planningplanning

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

Transfer of care (TOC) Transfer of care (TOC) policypolicy

Patients with acute, chronic or serious Patients with acute, chronic or serious condition, surgery already approved by condition, surgery already approved by the payer or a terminal illness may stay the payer or a terminal illness may stay with their non-MPN provider for with their non-MPN provider for specified times:specified times: Acute condition – for up to 30 daysAcute condition – for up to 30 days Serious, chronic – for up to 12 monthsSerious, chronic – for up to 12 months Surgery-to occur within 180 days of MPN Surgery-to occur within 180 days of MPN

coverage effective datecoverage effective date Terminal illness- for duration of illness Terminal illness- for duration of illness

Transfer of care policyTransfer of care policy

Disputes over transfer of care Disputes over transfer of care determinations must be handled via determinations must be handled via LC 4062LC 4062

Employee must be sent a Employee must be sent a “determination” regarding their “determination” regarding their condition if subject to transfer of carecondition if subject to transfer of care

If employee disputes determination, If employee disputes determination, PTP shall be asked to address whether PTP shall be asked to address whether patient falls within TOC conditionspatient falls within TOC conditions

MPN issues for claims MPN issues for claims administratorsadministrators

Be familiar with the policies and Be familiar with the policies and network(s) of the particular MPN(s) you network(s) of the particular MPN(s) you are using:are using: Each MPN must have a MPN contactEach MPN must have a MPN contact Educate your policyholders about MPNEducate your policyholders about MPN

Referral into network for first visitReferral into network for first visit Provide information for injured workersProvide information for injured workers

How to change physicianHow to change physician continuity of carecontinuity of care How to get provider listingHow to get provider listing transfer of caretransfer of care Out of network care/out of area careOut of network care/out of area care 22ndnd and 3 and 3rdrd opinion opinion IMRIMR

MPN issues for providersMPN issues for providers

Are you in the MPN networks?Are you in the MPN networks? Provider contractsProvider contracts Provider nominationsProvider nominations

How to refer patients within MPNHow to refer patients within MPN Access issuesAccess issues What if you are asked to perform a What if you are asked to perform a

22ndnd/3/3rdrd opinion? opinion? How do I become an IMR physician?How do I become an IMR physician?

MonitoringMonitoring

Complaints and problems are to be Complaints and problems are to be expected in a change this majorexpected in a change this major

MPNs should have a mechanism to MPNs should have a mechanism to monitor problems like:monitor problems like: Access (geographic, temporal-time to Access (geographic, temporal-time to

appt)appt) Provider choiceProvider choice Employees not having info they needEmployees not having info they need Provider network listingsProvider network listings

Other issuesOther issues

Draft final MPN regulations on our Draft final MPN regulations on our website Final regulations due around website Final regulations due around March 1stMarch 1st

If we fail to meet 60 day deadline we will If we fail to meet 60 day deadline we will notify you with a letter stating that your notify you with a letter stating that your application has been approved “by application has been approved “by default” – don’t just assume you can default” – don’t just assume you can declare your own approval date—DWC is declare your own approval date—DWC is tracking the dates for each application.tracking the dates for each application.

Other issuesOther issues

How will you coordinate MPN How will you coordinate MPN arrangements with UR, treatment arrangements with UR, treatment guidelines, new AMA disability rating guidelines, new AMA disability rating guides, RTW efforts?guides, RTW efforts?

Quality of care/accessQuality of care/access Patient satisfactionPatient satisfaction CostsCosts Disputes about MPNsDisputes about MPNs Changing MPNs-new notice requirementsChanging MPNs-new notice requirements

Independent Medical Independent Medical ReviewReview

Only for employees in MPNsOnly for employees in MPNs Treatment or diagnostic dispute Treatment or diagnostic dispute

between the injured worker and PTPbetween the injured worker and PTP The injured worker must seek a The injured worker must seek a

second and third opinion from second and third opinion from physicians in the MPN before the physicians in the MPN before the IMRIMR

Independent Medical Independent Medical ReviewersReviewers

Eligible physicians:Eligible physicians: Medical Doctors (MD’s)Medical Doctors (MD’s) Doctors of Osteopathy (DO’s)Doctors of Osteopathy (DO’s) PodiatristsPodiatrists (Psychologists)(Psychologists)

Must be board certifiedMust be board certified Others not eligible per the Labor Others not eligible per the Labor

CodeCode

Process - MPNProcess - MPN

MPN contact sends form to IW at MPN contact sends form to IW at time of selection of third opinion time of selection of third opinion physicianphysician Include specialty of treating physician Include specialty of treating physician

and alternate physicianand alternate physician

Process - Injured WorkerProcess - Injured Worker

Wait until after the third opinionWait until after the third opinion

If still has dispute, may ask for IMRIf still has dispute, may ask for IMR

Select paper review or in-person Select paper review or in-person examinationexamination

May designate alternate specialtyMay designate alternate specialty

Process - DWCProcess - DWC

Review form, select specialtyReview form, select specialty Select physician randomly within 30 Select physician randomly within 30

miles, if possible, for in-person miles, if possible, for in-person examinationexamination

For record review will select For record review will select randomly from that entire specialtyrandomly from that entire specialty

Notify the selected reviewer and the Notify the selected reviewer and the partiesparties

Process (Continued)Process (Continued)

All have 10 days to check for a conflictAll have 10 days to check for a conflict If none, injured worker has 60 from If none, injured worker has 60 from

receipt of the name to make an receipt of the name to make an appointmentappointment

IMR should give an appointment within IMR should give an appointment within 20 days of call20 days of call

IMR issues report within 20 days of the IMR issues report within 20 days of the appointment except for emergenciesappointment except for emergencies

ResultsResults

AD will adopt the doctor’s findings and AD will adopt the doctor’s findings and will issue a written determinationwill issue a written determination

If the IMR doctor does not agree with the If the IMR doctor does not agree with the treating physician’s service/treatment, the treating physician’s service/treatment, the injured worker may seek that injured worker may seek that service/treatment outside the MPN. The service/treatment outside the MPN. The provided treatment must be consistent provided treatment must be consistent with AD’s guidelines.with AD’s guidelines.

After that service/treatment, the IW After that service/treatment, the IW returns to the MPN for future needs.returns to the MPN for future needs.