DWC Update on Medical Provider Networks

1
DWC Update on Medical Provider Networks

• Yu-Yee Wu, Industrial Relations Counsel
• California Division of Workers Compensation
• CCWC Conference
• July 13, 2006

2
MPN Overview

• As of June 30, 2006
• 1222 MPN applications have been received since
  November 1, 2004
• 1079 MPNs approved
• 11 MPNs revoked
• 34 MPNs withdrawn

3
Breakdown of MPN Applicants(as of June 30, 2006)

• Insurer 59.8 (693)
• Self-insured Employer 35.6 (415)
• Joint Powers Authority 3.2 (37)
• State 0.2 (2)
• Group self insured employer 1.3 (15)
• CIGA 0.1 (1)

4
MPN Permanent Regulations 8 CCR 9767.1 et seq.
Some Key Changes

• Applicant must confirm that its provider
  contracts specifically provide for treatment to
  injured workers in WC system
• Requires MPN to have at least 3 physicians of
  each common specialty within the access standards
• Out-of-Network Access MPNs to provide at least
  three referrals when employee lives or works
  outside MPN service area
• Requires 30-day notice of implementation of a MPN
• Any website directories must be accessible
  (including disclosure of any passwords)

5
MPN Permanent Regulations More Key Changes

• Requires a regional area listing to be given to
  employees
• A Regional Area Listing has ALL MPN providers
  (PTPs and specialists) within the 15 mile radius,
  or a larger radius if needed to ensure at least 3
  specialists of each kind included
• Makes transfer of care and continuity of care
  language more comparable in
• Definitions and time frames of conditions
• Dispute resolution procedure under Labor Code
  4062
• 20-day period for PTP to issue report on
  qualifying conditions
• NOTE 20 days starts from day the employee
  requests the report from the PTP

6
Operational Issues

• Provider Access Problems
• Regional List not given or not accessible on web
• Provider not taking WC patients
• Insufficient number of physicians in specialty
• Consequences
• Complaints to DWC
• Litigation Expedited Hearings before WCAB
• Loss of control over employees medical treatment

7
Material Modification ProcessWhat if I have
changes to my MPN?

• Submit the Notice of MPN Plan Modification Form
  (8 CCR 9767.8)
• Change in the DWC Liaison
• 10 change in network providers
• 25 change in the number of covered employees
• Change in applicant status, e.g., self-insured to
  insured
• NOTE The filing of a Notice of Material
  Modification triggers an update to the permanent
  regulations of all the MPN policies and materials

8
What should I do if I want to change to a
different MPN?

• Contact DWC as early as possible for guidance on
  avoiding gaps in MPN coverage during the change
  of MPNs
• File a Notice of MPN Plan Modification with DWC
  regarding change of MPNs
• Attach a sample notice to employees
• NOTE New MPN must file material modification
  if number of covered employees change at least
  25
• Distribute 30-day notice to employees of a change
  of MPNs with new MPN employee materials
• If terminating old MPN, contact DWC for further
  guidance

9
What if I want to terminate or stop using a MPN?

• Contact DWC as early as possible for guidance
• File a Notice of MPN Plan Modification with DWC
  before the termination
• Check Other and state that the MPN will be
  terminated or no longer used by applicant and
  attach a sample employee notice
• Distribute notice to employees of MPN termination
• NOTE MPN Termination regulations coming soon

10
What if I still have MPN questions?

• Medical Provider Network Website
  www.dir.ca.gov/dwc/MPN/DWC_MPN_Main.html
• Email Yu-YeeWu_at_dir.ca.gov
• Phone [phone]