Medical Provider Medical Provider NetworksNetworks

Overview and issues after Overview and issues after

one yearone year Kathy Dervin, M.P.H.Kathy Dervin, M.P.H.

Medical Unit/Managed Care Medical Unit/Managed Care ProgramProgram

DWC Educational ConferenceDWC Educational ConferenceMarch 1/2 and March 6/7, 2006March 1/2 and March 6/7, 2006

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

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

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 8 Calif. Code of Regulations §9767.1

et seqet seq Final regs in adopted Sept 15, 2005Final regs in adopted Sept 15, 2005

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

Permanent regulationsPermanent regulationsSee summary of all changes on website or regsSee summary of all changes on website or regs

Requires a 30 day notice periodRequires a 30 day notice period Defines “regional provider listing”Defines “regional provider listing” Applicant must confirm that a contract Applicant must confirm that a contract

( with providers) exists to provide ( with providers) exists to provide treatment to injured workers in wc systemtreatment to injured workers in wc system

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

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

Permanent regulations Permanent regulations (cont’d)(cont’d)

Clarifies when regional listing must Clarifies when regional listing must be provided or made availablebe provided or made available

Makes transfer of care and Makes transfer of care and continuity of care language more continuity of care language more comparable in:comparable in: Definitions of conditionsDefinitions of conditions Time frames for conditionsTime frames for conditions Dispute resolution process through LC Dispute resolution process through LC

§4062§4062

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

Self-insured employers, group self-Self-insured employers, group self-insurersinsurers

InsurersInsurers Joint Powers AuthoritiesJoint Powers Authorities State of Calif.State of Calif. CIGA, Self-insured Security FundCIGA, Self-insured Security Fund

First year of MPN activityFirst year of MPN activityNov 1, 2004 through Oct. 31, 2005Nov 1, 2004 through Oct. 31, 2005

1103 applications received 1103 applications received including:including: 13 ineligible13 ineligible 37 withdrawn by applicant37 withdrawn by applicant

968 MPNs approved968 MPNs approved

Types of MPN applicantsTypes of MPN applicantsNov 1, 04 through Oct 31, 05Nov 1, 04 through Oct 31, 05

% (n)% (n)

InsurerInsurer 60.5% (637) 60.5% (637) Self-insured EmployerSelf-insured Employer 35.7% (376) 35.7% (376) Joint Powers AuthorityJoint Powers Authority 3.3 % (35) 3.3 % (35) StateState 0.3% (3) 0.3% (3) Group self insured employer 0.2% (2)Group self insured employer 0.2% (2) CIGA CIGA 0.1% (1) 0.1% (1)

How many payers and How many payers and employees do MPNs cover employees do MPNs cover

after one year?after one year? Using an estimate of % of payers who have Using an estimate of % of payers who have

established a MPN and their market share, established a MPN and their market share, ~ 55 % of employees are now covered by a ~ 55 % of employees are now covered by a

payer payer that has that has establishedestablished a MPN between a MPN between Jan 1, 2005 and Nov 1, 2005Jan 1, 2005 and Nov 1, 2005

Implementation of coverage unclearImplementation of coverage unclear Status of transfer of care into MPNs unclearStatus of transfer of care into MPNs unclear Rapid adoption and implementation of Rapid adoption and implementation of

MPNsMPNs

Networks being used in Networks being used in MPNsMPNs

First HealthFirst Health Prudent Buyer (Blue Cross of Calif.)Prudent Buyer (Blue Cross of Calif.) KaiserKaiser CorVelCorVel ConcentraConcentra InterplanInterplan MedexMedex Wellcomp, Status Care, othersWellcomp, Status Care, others Customized networksCustomized networks

MPN access standardsMPN access standards

Geographic access standardsGeographic access standards Primary care -- 15 milesPrimary care -- 15 miles Hospital -- 15 milesHospital -- 15 miles Specialist/occupational health -- 30 milesSpecialist/occupational health -- 30 miles

Time to appointmentTime to appointment 11stst visit within 3 business days visit within 3 business days Specialist appt. within 20 daysSpecialist appt. within 20 days

Rural area –alternative standards Rural area –alternative standards permissiblepermissible

Out of network standardsOut of network standards

Access to care in MPNs: Access to care in MPNs: IssuesIssues

List not given promptly, not given at allList not given promptly, not given at all List not accessible on websiteList not accessible on website List inadequate (full regional list not List inadequate (full regional list not

provided)provided) Providers on list won’t take injured Providers on list won’t take injured

worker as patient:worker as patient: Doesn’t take WCDoesn’t take WC Not taking new WC patientsNot taking new WC patients Won’t take post-operative case Won’t take post-operative case Won’t take “difficult” case w/ complicationsWon’t take “difficult” case w/ complications

Employee notificationEmployee notification

Once MPN is approved notice is required: Once MPN is approved notice is required: Initial notice - 30 days before effective dateInitial notice - 30 days before effective date Time of injury noticeTime of injury notice Notice of IMR at request for 3Notice of IMR at request for 3rdrd opinion when opinion when

diagnosis or treatment is being contesteddiagnosis or treatment is being contested Choice of physician and provider directoryChoice of physician and provider directory All notices must be in English and SpanishAll notices must be in English and Spanish Don’t send Spanish speakers info on MPN in Don’t send Spanish speakers info on MPN in

English !English !

MPN provider listingsMPN provider listings

Provider listings must be available to Provider listings must be available to covered employeescovered employees

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

Hard copies must ALSO be readily Hard copies must ALSO be readily availableavailable

Regional listingRegional listing Full listing, upon requestFull listing, upon request

What is a regional What is a regional listing?listing?

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

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

This listing must be readily available This listing must be readily available to covered employeesto covered employees

Web listings, hard copies, in SpanishWeb listings, hard copies, in Spanish

Medical disputes over Medical disputes over treatment in MPNstreatment in MPNs

UR approval or denial UR approval or denial LC §4062 LC §4062 Disagreement over diagnosis or Disagreement over diagnosis or

treatmenttreatment Change physicians within MPN is Change physicians within MPN is

first optionfirst option Second opinionSecond opinion Third opinionThird opinion Independent Medical ReviewIndependent Medical Review

Second and third opinion Second and third opinion IMR IMR

• Employee tells MPN they want a second Employee tells MPN they want a second opinionopinion

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

• MPN contacts 2MPN contacts 2ndnd opinion physician, sends opinion physician, sends medical recordsmedical records

• 22ndnd opinion physician writes report opinion physician writes report• If agrees with patient, care is provided within If agrees with patient, care is provided within

MPNMPN• If agrees with PTP, patient can go on to 3If agrees with PTP, patient can go on to 3rdrd

opinionopinion

Second and third opinion Second and third opinion IMR IMR

33rdrd opinion repeats process. At time of 3 opinion repeats process. At time of 3rdrd opinion, MPN must notify patient about IMRopinion, MPN must notify patient about IMR

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

IMR reviewer reviews all reportIMR reviewer reviews all report Supports patient-care care be given outside Supports patient-care care be given outside

MPNMPN Supports 3 previous physicians-care continues in Supports 3 previous physicians-care continues in

MPNMPN

IMRIMR

DWC Medical Unit has recruited DWC Medical Unit has recruited IMR physiciansIMR physicians

Process set forth in Title 8 CCR Process set forth in Title 8 CCR §9768§9768

No valid IMR request has yet been No valid IMR request has yet been receivedreceived

Transfer of Care PolicyTransfer of Care Policy

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, allWhich 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 processTransfer of care process

Steps:Steps: 1) Determine whether the injured 1) Determine whether the injured

employee has a condition allowing them to employee has a condition allowing them to stay with current doctorstay with current doctor

AcuteAcute Serious/chronicSerious/chronic Surgery authorized and set within 180 days of Surgery authorized and set within 180 days of

MPN startMPN start Terminal illnessTerminal illness

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

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

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

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

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

MonitoringMonitoring

MPNs should have a mechanism to monitor MPNs should have a mechanism to monitor :: Access (geographic, temporal-time to appt)Access (geographic, temporal-time to appt)

MPN must help employees having trouble getting an MPN must help employees having trouble getting an appointmentappointment

Provider choices, providers taking new patientsProvider choices, providers taking new patients Employees not having info they needEmployees not having info they need Provider network listingsProvider network listings Out of area care, referrals out of networkOut of area care, referrals out of network Complaints and problemsComplaints and problems

MPN Complaint ProcessMPN Complaint Process Complaints from workers, providers, Complaints from workers, providers,

attnys, insured employersattnys, insured employers DWC gathers info to ID compliance issues DWC gathers info to ID compliance issues

or problem areaor problem area DWC contacts MPN liaison personDWC contacts MPN liaison person MPN asked to investigate and report to MPN asked to investigate and report to

DWC DWC If problem exists:If problem exists:

Correct for individual caseCorrect for individual case See that MPN See that MPN proceduresprocedures are correct and are correct and

followedfollowed

Ongoing MPN Ongoing MPN compliancecompliance

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

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

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

MPN resources on DWC MPN resources on DWC websitewebsite

RegulationsRegulations MPN coverpage, material modification MPN coverpage, material modification

pagepage Frequently asked questions for Frequently asked questions for

applicants and MPNsapplicants and MPNs Summary of permanent reg changesSummary of permanent reg changes Sample MPN employee notice (updated)Sample MPN employee notice (updated) List of all approved MPNsList of all approved MPNs Dear provider letter on how to get into Dear provider letter on how to get into

MPNMPN

QUESTIONS ?