Medical Provider Networks Overview and issues after one year

1. 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

2. 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)

3. 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

4. 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

5. 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

6. Who can set up a MPN? • Self-insured employers, group self-insurers • Insurers • Joint Powers Authorities • State of Calif. • CIGA, Self-insured Security Fund

7. First year of MPN activityNov 1, 2004 through Oct. 31, 2005 • 1103 applications received including: • 13 ineligible • 37 withdrawn by applicant • 968 MPNs approved

8. 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)

9. 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

10. Networks being used in MPNs • First Health • Prudent Buyer (Blue Cross of Calif.) • Kaiser • CorVel • Concentra • Interplan • Medex • Wellcomp, Status Care, others • Customized networks

11. 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

12. 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

13. 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 !

14. 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

15. 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

16. 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

17. 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

18. 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

19. IMR • DWC Medical Unit has recruited IMR physicians • Process set forth in Title 8 CCR §9768 • No valid IMR request has yet been received

20. 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

21. 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)

22. 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.

23. Monitoring • 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

24. 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

25. 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

26. 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

27. QUESTIONS ?