Medical Provider Networks Kathy Dervin, M.P.H. and Anne Searcy, M.D. DWC Educational Conference February/March, 2005

Choices for medical care in workers’ compensation Pre-designation per LC 4600 Pre-designation per LC day control 30 day control Labor-Management agreements (“carve-outs) Labor-Management agreements (“carve-outs) Permits 24 hour-like integration pilots Permits 24 hour-like integration pilots Health Care Organizations Health Care Organizations Medical Provider Networks Medical Provider Networks Non-directed care (employee choice) Non-directed care (employee choice)

Medical Provider Networks: Overview Medical Provider Networks: Overview Labor Code 4616 Labor Code Calif. Code of Regulations et esq. 8 Calif. Code of Regulations et esq. Emergency regs in effect Emergency regs in effect Final rules under review for adoption March 1 Final rules under review for adoption March rules on Independent Medical Review 9768 rules on Independent Medical Review Effective date of MPNs January 1, 2005 Effective date of MPNs January 1, 2005

Who can set up an MPN? Self-insured employers Self-insured employers Insurers Insurers Joint Powers Authorities Joint Powers Authorities State of California (agencies of) State of California (agencies of)

Who can not set up an MPN? Provider networks Provider networks Insured employers Insured employers TPAs TPAs Clinics or provider groups Clinics or provider groups Medical management/UR companies Medical management/UR companies

MPN Implementation Process Application process to DWC (stage we are in now) Application process to DWC (stage we are in now) Start up of new MPN coverage (just beginning) Start up of new MPN coverage (just beginning) Expansion of MPNs Expansion of MPNs New injuries New injuries Transfer of care Transfer of care Monitoring Monitoring Evaluation (to be determined) Evaluation (to be determined)

MPN application process Eligible applicant organization submits application to DWC Eligible applicant organization submits application to DWC DWC has 60 days to act on a complete application: DWC has 60 days to act on a complete application: Ineligible Ineligible Incomplete Incomplete Deficient  Disapproved Deficient  Disapproved Approved Approved

Standards for MPNs Adequate number and type of providers to meet the needs of the employer’s common injuries based on type of industry and occupation Adequate number and type of providers to meet the needs of the employer’s common injuries based on type of industry and occupation Access to specific types of providers ( including those mentioned in LC and ) Access to specific types of providers ( including those mentioned in LC and ) Mix of occupational and non-occupational providers (goal of 25 % non-occ) Mix of occupational and non-occupational providers (goal of 25 % non-occ) Defined geographic service area and number of employees to be covered Defined geographic service area and number of employees to be covered

Standards for MPNs Access standards Access standards Primary care Primary care Hospital Hospital Specialist/occupational Specialist/occupational Continuity of care policy Continuity of care policy Transfer of care policy Transfer of care policy Economic profiling policy-if present Economic profiling policy-if present

Standards for MPNs Employee Notification Employee Notification Choice of physician and provider directory Choice of physician and provider directory Second and third opinion process Second and third opinion process Not med-legal, but a treatment second opinion when dispute over diagnosis or treatment Not med-legal, but a treatment second opinion when dispute over diagnosis or treatment Independent Medical Review Independent Medical Review

How to put together a MPN application Read regulations Read regulations Follow regulations Follow regulations Choose compatible network and partners Choose compatible network and partners Submit complete application to DWC Submit complete application to DWC Other resources: Other resources: Frequently Asked Questions on MPNs Frequently Asked Questions on MPNs Sample employee notice Sample employee notice Follow the regulations (did I say this?) Follow the regulations (did I say this?)

Key issues: Employee notification MPNs are new MPNs are new New things are confusing New things are confusing They represent a big change in wc medical care and choice of provider They represent a big change in wc medical care and choice of provider Change can be confusing and unsettling…. Change can be confusing and unsettling…. Which bring us to employee notification…….. Which bring us to employee notification……..

Employee notification Follow the regulations—specifically and (IMR notice) Follow the regulations—specifically and (IMR notice) Before implementation of a MPN, covered employees must be given a written notice (English and Spanish) Before implementation of a MPN, covered employees must be given a written notice (English and Spanish) At time of injury, notice must be given At time of injury, notice must be given After first visit employee must be told of their right to chose a(nother) physician and how to access the MPN provider directory (LC 4616(b)) After first visit employee must be told of their right to chose a(nother) physician and how to access the MPN provider directory (LC 4616(b)) At time of 3 rd opinion request IMR notice must be given At time of 3 rd opinion request IMR notice must be given

Things not to put in your employee notification Mandatory forms that are not in the regulations Mandatory forms that are not in the regulations New time frames not in the regulations New time frames not in the regulations Restrictions on change of physician Restrictions on change of physician Obligations on covered employees that are not in the regulations Obligations on covered employees that are not in the regulations Restrictions on choice of physician (except as allowed on appropriateness) Restrictions on choice of physician (except as allowed on appropriateness)

Common problems with employee notifications Employee must use a mandatory form to request 2 nd or 3 rd opinion Employee must use a mandatory form to request 2 nd or 3 rd opinion Employee must request 2 nd or 3 rd opinion with or any number of days Employee must request 2 nd or 3 rd opinion with or any number of days Changing wording of regulatory requirements, time frames set forth in regs Changing wording of regulatory requirements, time frames set forth in regs Not disclosing employee rights in MPN Not disclosing employee rights in MPN Restrictions to provider listing Restrictions to provider listing Regs allow regional listing but full listing must also be made available Regs allow regional listing but full listing must also be made available

So—how many MPNs are there? DWC has received over 600 applications since November 1 st. DWC has received over 600 applications since November 1 st. 80 have been approved as of February 12th 80 have been approved as of February 12th List of approvals at List of approvals at Many have been disapproved Many have been disapproved Many are still in the review process Many are still in the review process Many are still coming in—we expect to review between ~750 and 2000 applications Many are still coming in—we expect to review between ~750 and 2000 applications

Start Up and Implementation Once a MPN is approved—notify your covered employees using your approved employee notification materials/letters Once a MPN is approved—notify your covered employees using your approved employee notification materials/letters New Injuries – referral into MPN initial provider New Injuries – referral into MPN initial provider MPN contact to perform required functions- make sure information is available MPN contact to perform required functions- make sure information is available Existing injuries: to transfer or not to transfer? Existing injuries: to transfer or not to transfer?

Transfer of Care Written transfer of care policy to guide this process Written transfer of care policy to guide this process Will you transfer open claims? Will you transfer open claims? Is the treating physician in your network already? If yes, no need to transfer 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 Which cases will you transfer-none, some, all—how many open claims do you have—needs planning Must follow the policy set forth in to determine whether and when care can be transferred Must follow the policy set forth in to determine whether and when care can be transferred

Transfer of care (TOC) policy Patients with acute, chronic or serious condition, surgery already approved by the payer or a terminal illness may stay with their non-MPN provider for specified times: Patients with acute, chronic or serious condition, surgery already approved by the payer or a terminal illness may stay with their non-MPN provider for specified times: Acute condition – for up to 30 days Acute condition – for up to 30 days Serious, chronic – for up to 12 months Serious, chronic – for up to 12 months Surgery-to occur within 180 days of MPN coverage effective date Surgery-to occur within 180 days of MPN coverage effective date Terminal illness- for duration of illness Terminal illness- for duration of illness

Transfer of care policy Disputes over transfer of care determinations must be handled via LC 4062 Disputes over transfer of care determinations must be handled via LC 4062 Employee must be sent a “determination” regarding their condition if subject to transfer of care Employee must be sent a “determination” regarding their condition if subject to transfer of care If employee disputes determination, PTP shall be asked to address whether patient falls within TOC conditions If employee disputes determination, PTP shall be asked to address whether patient falls within TOC conditions

MPN issues for claims administrators Be familiar with the policies and network(s) of the particular MPN(s) you are using: Be familiar with the policies and network(s) of the particular MPN(s) you are using: Each MPN must have a MPN contact Each MPN must have a MPN contact Educate your policyholders about MPN Educate your policyholders about MPN Referral into network for first visit Referral into network for first visit Provide information for injured workers Provide information for injured workers How to change physiciancontinuity of care How to change physiciancontinuity of care How to get provider listingtransfer of care How to get provider listingtransfer of care Out of network care/out of area care Out of network care/out of area care 2 nd and 3 rd opinion 2 nd and 3 rd opinion IMR IMR

MPN issues for providers Are you in the MPN networks? Are you in the MPN networks? Provider contracts Provider contracts Provider nominations Provider nominations How to refer patients within MPN How to refer patients within MPN Access issues Access issues What if you are asked to perform a 2 nd /3 rd opinion? What if you are asked to perform a 2 nd /3 rd opinion? How do I become an IMR physician? How do I become an IMR physician?

Monitoring Complaints and problems are to be expected in a change this major Complaints and problems are to be expected in a change this major MPNs should have a mechanism to monitor problems like: MPNs should have a mechanism to monitor problems like: Access (geographic, temporal-time to appt) Access (geographic, temporal-time to appt) Provider choice Provider choice Employees not having info they need Employees not having info they need Provider network listings Provider network listings

Other issues Draft final MPN regulations on our website Final regulations due around March 1st Draft final MPN regulations on our website Final regulations due around March 1st If we fail to meet 60 day deadline we will notify you with a letter stating that your application has been approved “by default” – don’t just assume you can declare your own approval date—DWC is tracking the dates for each application. If we fail to meet 60 day deadline we will notify you with a letter stating that your application has been approved “by default” – don’t just assume you can declare your own approval date—DWC is tracking the dates for each application.

Other issues How will you coordinate MPN arrangements with UR, treatment guidelines, new AMA disability rating guides, RTW efforts? How will you coordinate MPN arrangements with UR, treatment guidelines, new AMA disability rating guides, RTW efforts? Quality of care/access Quality of care/access Patient satisfaction Patient satisfaction Costs Costs Disputes about MPNs Disputes about MPNs Changing MPNs-new notice requirements Changing MPNs-new notice requirements

Independent Medical Review Only for employees in MPNs Only for employees in MPNs Treatment or diagnostic dispute between the injured worker and PTP Treatment or diagnostic dispute between the injured worker and PTP The injured worker must seek a second and third opinion from physicians in the MPN before the IMR The injured worker must seek a second and third opinion from physicians in the MPN before the IMR

Independent Medical Reviewers Eligible physicians: Eligible physicians: Medical Doctors (MD’s) Medical Doctors (MD’s) Doctors of Osteopathy (DO’s) Doctors of Osteopathy (DO’s) Podiatrists Podiatrists (Psychologists) (Psychologists) Must be board certified Must be board certified Others not eligible per the Labor Code Others not eligible per the Labor Code

Process - MPN MPN contact sends form to IW at time of selection of third opinion physician MPN contact sends form to IW at time of selection of third opinion physician Include specialty of treating physician and alternate physician Include specialty of treating physician and alternate physician

Process - Injured Worker Wait until after the third opinion Wait until after the third opinion If still has dispute, may ask for IMR If still has dispute, may ask for IMR Select paper review or in-person examination Select paper review or in-person examination May designate alternate specialty May designate alternate specialty

Process - DWC Review form, select specialty Review form, select specialty Select physician randomly within 30 miles, if possible, for in-person examination Select physician randomly within 30 miles, if possible, for in-person examination For record review will select randomly from that entire specialty For record review will select randomly from that entire specialty Notify the selected reviewer and the parties Notify the selected reviewer and the parties

Process (Continued) All have 10 days to check for a conflict All have 10 days to check for a conflict If none, injured worker has 60 from receipt of the name to make an appointment If none, injured worker has 60 from receipt of the name to make an appointment IMR should give an appointment within 20 days of call IMR should give an appointment within 20 days of call IMR issues report within 20 days of the appointment except for emergencies IMR issues report within 20 days of the appointment except for emergencies

Results AD will adopt the doctor’s findings and will issue a written determination AD will adopt the doctor’s findings and will issue a written determination If the IMR doctor does not agree with the treating physician’s service/treatment, the injured worker may seek that service/treatment outside the MPN. The provided treatment must be consistent with AD’s guidelines. If the IMR doctor does not agree with the treating physician’s service/treatment, the injured worker may seek that service/treatment outside the MPN. The provided treatment must be consistent with AD’s guidelines. After that service/treatment, the IW returns to the MPN for future needs. After that service/treatment, the IW returns to the MPN for future needs.