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) Pre-designation LC §4600/CCR § 9783 (new) 30 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 seq 8 Calif. Code of Regulations § et seq Final regs in adopted Sept 15, 2005 Final regs in adopted Sept 15, Calif. Code of Regulations §9768 for Independent Medical Review 8 Calif. Code of Regulations §9768 for Independent Medical Review

Permanent regulations See summary of all changes on website or regs Requires a 30 day notice period Requires a 30 day notice period Defines “regional provider listing” Defines “regional provider listing” Applicant must confirm that a contract ( with providers) exists to provide treatment to injured workers in wc system 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 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 Clarifies MPN obligations when employee lives or works outside service area

Permanent regulations (cont’d) Clarifies when regional listing must be provided or made available Clarifies when regional listing must be provided or made available Makes transfer of care and continuity of care language more comparable in: Makes transfer of care and continuity of care language more comparable in: Definitions of conditions Definitions of conditions Time frames for conditions Time frames for conditions Dispute resolution process through LC §4062 Dispute resolution process through LC §4062

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

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through Oct. 31, applications received including: 1103 applications received including: 13 ineligible 13 ineligible 37 withdrawn by applicant 37 withdrawn by applicant 968 MPNs approved 968 MPNs approved

Types of MPN applicants Nov 1, 04 through Oct 31, 05 % (n) % (n) Insurer 60.5% (637) Insurer 60.5% (637) Self-insured Employer 35.7% (376) Self-insured Employer 35.7% (376) Joint Powers Authority 3.3 % (35) Joint Powers Authority 3.3 % (35) State 0.3% (3) State 0.3% (3) Group self insured employer 0.2% (2) Group self insured employer 0.2% (2) CIGA 0.1% (1) CIGA 0.1% (1)

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, 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 ~ 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 Implementation of coverage unclear Status of transfer of care into MPNs unclear Status of transfer of care into MPNs unclear Rapid adoption and implementation of MPNs Rapid adoption and implementation of MPNs

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

MPN access standards Geographic access standards Geographic access standards Primary care miles Primary care miles Hospital miles Hospital miles Specialist/occupational health miles Specialist/occupational health miles Time to appointment Time to appointment 1 st visit within 3 business days 1 st visit within 3 business days Specialist appt. within 20 days Specialist appt. within 20 days Rural area –alternative standards permissible Rural area –alternative standards permissible Out of network standards Out of network standards

Access to care in MPNs: Issues List not given promptly, not given at all List not given promptly, not given at all List not accessible on website List not accessible on website List inadequate (full regional list not provided) List inadequate (full regional list not provided) Providers on list won’t take injured worker as patient: Providers on list won’t take injured worker as patient: Doesn’t take WC Doesn’t take WC Not taking new WC patients Not taking new WC patients Won’t take post-operative case Won’t take post-operative case Won’t take “difficult” case w/ complications Won’t take “difficult” case w/ complications

Employee notification Once MPN is approved notice is required: Once MPN is approved notice is required: Initial notice - 30 days before effective date Initial notice - 30 days before effective date Time of injury notice Time of injury notice Notice of IMR at request for 3 rd opinion when diagnosis or treatment is being contested Notice of IMR at request for 3 rd opinion when diagnosis or treatment is being contested Choice of physician and provider directory Choice of physician and provider directory All notices must be in English and Spanish All notices must be in English and Spanish Don’t send Spanish speakers info on MPN in English ! Don’t send Spanish speakers info on MPN in English !

MPN provider listings Provider listings must be available to covered employees Provider listings must be available to covered employees Web version must be accessible (w/any passwords being used) Web version must be accessible (w/any passwords being used) Hard copies must ALSO be readily available Hard copies must ALSO be readily available Regional listing Regional listing Full listing, upon request Full listing, upon request

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 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 A county listing of all MPN providers where the employee lives or works This listing must be readily available to covered employees This listing must be readily available to covered employees Web listings, hard copies, in Spanish Web listings, hard copies, in Spanish

Medical disputes over treatment in MPNs UR approval or denial  LC §4062 UR approval or denial  LC §4062 Disagreement over diagnosis or treatment Disagreement over diagnosis or treatment Change physicians within MPN is first option Change physicians within MPN is first option Second opinion Second opinion Third opinion Third opinion Independent Medical Review Independent Medical Review

Second and third opinion  IMR Employee tells MPN they want a second opinion Employee tells MPN they want a second opinion MPN makes sure employee has provider list to choose from, chooses a physician MPN makes sure employee has provider list to choose from, chooses a physician MPN contacts 2 nd opinion physician, sends medical records MPN contacts 2 nd opinion physician, sends medical records 2 nd opinion physician writes report 2 nd opinion physician writes report If agrees with patient, care is provided within MPN If agrees with patient, care is provided within MPN If agrees with PTP, patient can go on to 3 rd opinion If agrees with PTP, patient can go on to 3 rd opinion

Second and third opinion  IMR 3 rd opinion repeats process. At time of 3 rd opinion, MPN must notify patient about IMR 3 rd opinion repeats process. At time of 3 rd opinion, MPN must notify patient about IMR If patient disagrees with 3 rd opinion, fills out a IMR request form (to be provided by MPN/claims adjuster and sent to DWC Medical Unit) If patient disagrees with 3 rd 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 IMR reviewer reviews all report Supports patient-care care be given outside MPN Supports patient-care care be given outside MPN Supports 3 previous physicians-care continues in MPN Supports 3 previous physicians-care continues in MPN

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

Transfer of Care Policy 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 process Steps: Steps: 1) Determine whether the injured employee has a condition allowing them to stay with current doctor 1) Determine whether the injured employee has a condition allowing them to stay with current doctor Acute Acute Serious/chronic Serious/chronic Surgery authorized and set within 180 days of MPN start Surgery authorized and set within 180 days of MPN start Terminal illness Terminal illness 2) Send a letter informing the employee of the determination (in Spanish if employee speaks Spanish) 2) Send a letter informing the employee of the determination (in Spanish if employee speaks Spanish)

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. 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 ) If payer contests physician report, and wants to proceed with transfer, dispute must be resolved under ) While dispute is being settled treatment employee continues treatment with PT. PTP continues to control referrals until transfer is complete. 5) While dispute is being settled treatment employee continues treatment with PT. PTP continues to control referrals until transfer is complete.

Monitoring 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 appointment MPN must help employees having trouble getting an appointment Provider choices, providers taking new patients Provider choices, providers taking new patients Employees not having info they need Employees not having info they need Provider network listings Provider network listings Out of area care, referrals out of network Out of area care, referrals out of network Complaints and problems Complaints and problems

MPN Complaint Process Complaints from workers, providers, attnys, insured employers Complaints from workers, providers, attnys, insured employers DWC gathers info to ID compliance issues or problem area DWC gathers info to ID compliance issues or problem area DWC contacts MPN liaison person DWC contacts MPN liaison person MPN asked to investigate and report to DWC MPN asked to investigate and report to DWC If problem exists: If problem exists: Correct for individual case Correct for individual case See that MPN procedures are correct and followed See that MPN procedures are correct and followed

Ongoing MPN compliance Approved MPNs must continue to meet all of the standards they were approved under or may face suspension/revocation of approval 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 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 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 Regulations Regulations MPN coverpage, material modification page MPN coverpage, material modification page Frequently asked questions for applicants and MPNs Frequently asked questions for applicants and MPNs Summary of permanent reg changes Summary of permanent reg changes Sample MPN employee notice (updated) Sample MPN employee notice (updated) List of all approved MPNs List of all approved MPNs Dear provider letter on how to get into MPN Dear provider letter on how to get into MPN

QUESTIONS ?