Workers Compensation Reform 2012 Part II: Medical Provider Networks

Workers Compensation Reform 2012 Part II: Medical Provider Networks

In 2004, Senate Bill 899 was a devastating reform to injured workers. One of these workers compensation reforms in 2004 was the elimination of your ability to have a free choice of treating work comp physician. After 2004 you are required to choose a physician from the employer or insurance companies handpicked list of physicians who in most cases are beholden to the insurance companies. Since 2004 these medical provider networks have been a constant problem for injured workers. The workers compensation attorneys at Cleveland and Metz have amassed a large knowledge of these medical provider networks and can help the injured worker choose the right treating physician and have done so for many injured workers in the Inland Empire.

Senate Bill 863 introduced new concepts into workers compensation medical provider networks. There are some improvements with this reform however they much outweigh the negatives. It is extremely difficult to get out of a medical provider network after the passage of this bill and a tightening of these rules. Many insurance companies and administrators have very restrictive medical provider networks meaning that most of the doctors in their networks are completely beholden to them or traditionally have been very anti-worker in their treatment and diagnosis of injured workers. The reason for this is that the workers compensation physician has to deal with the insurance carrier daily in order to get paid and run his business, the doctor only has to deal with the injured worker once or twice and send them on their way. We have found that over the last eight years that many doctors who formally practiced in workers compensation have been kicked out of all these networks thus narrowing down the field of doctors to choose from. Many of these networks are very fair however there is a growing number of them in my opinion that are becoming very sparse with doctors who will see you. Our workers compensation law knowledge of these medical provider networks can help you make critical choices in your case.

One of the major improvements from Senate Bill 863 is that doctors have to know that there in a medical provider network and provide written agreement that they are in the network. Over the last eight years we have found many doctors in these networks have no idea they are in the network and do not treat workers compensation patients. Many of these networks appear to be loaded with doctors however when you call each of them you find out that most of them do not handle workers compensation insurance. This improvement will remove hopefully most of the doctors listed so that there is a more accurate representation of the network. The administrators of these networks will have to verify that each physician on the network does take workers compensation patients.

The following is a list of questions and answers posted by the California Division of Worker’s Compensation:
How is the medical provider network (MPN) IMR process different from the IMR process specified in SB 863?

• The MPN IMR process is to resolve disagreements between an injured worker and the worker’s treating physician about necessary treatment (after the worker has obtained second and third opinions and still has not resolved the dispute). In contrast, the IMR process under SB 863 is to resolve disputes over a UR decision, where the treating physician and claims administrator disagree about necessary treatment.

 Are current MPNs required to go through their provider list and eliminate those providers who do not take workers’ compensation patients?

•  Yes, currently the MPN regulations require that the MPN providers must be willing to treat injured workers in the workers’ compensation system. Starting Jan. 1, 2014, SB 863 requires MPNs to post on their website a list of all treating physicians in the MPN and update the roster at least quarterly.

 Will the DWC require a modification filing of the MPN application and notices?

• Beginning Jan. 1, 2014, SB 863 requires that existing approved plans will be considered approved for a period of four years from the most recent application or modification approval date. MPNs must be re-approved every four years. Plans for reapproval of MPNs must be submitted at least six months before the expiration of the 4-year approval period.

 How does SB 863 help providers know when they are in an MPN?

•  Beginning Jan. 1, 2014, a treating physician will be included in a MPN only if the physician provides a separate written agreement to be in the network at the time of entering into or renewing the agreement to be in the network.