The California Medical Provider Network. in the Post SB863/SB542/AB1422 World

Transcription

1 The California Medical Provider Network in the Post SB863/SB542/AB1422 World

2 Presenter Tom Barnes Vice President Managed Care Legislation/Provider Network Management Gallagher Bassett Services, Inc.

3 Presentation Topics Senate Bills 863 & 542 The Value of Implementing a CA MPN 2014 CA MPN Regulations & Legislative Changes/Impacts for Employers MPN Definition Changes & Access Standards The Importance of the MPN Employee Notification Document Other California Employers Regulatory Requirements Assembly Bill 1422 Fraud Situations & Best Practices When Managing a Network Open Discussion/Questions and Answers

4 The Value of Implementing a CA MPN No MPN the employer directs medical care for 30 days. After 30 days, the employee may select his or her own treating physician. With MPN - the employer selects the initial treating physician from within the MPN and directs the employee to that physician for an initial visit. Thereafter an employee may select any medical provider within the MPN to provide further treatment. If an employee has properly predesignated their personal physician in both circumstances listed above, the employee may treat with their own personal physician from the moment of injury forward without consideration of the employer s right to control medical care for the first 30 days or an employer s MPN.

5 2014 CA MPN Regulations & Legislative Changes/Impacts for Employers MPN Employee Notifications are only required at time of injury or when the injury is reported MPN Notices (one-page) are not required when a MPN is implemented or when an employee is hired MPN Employee Notification Documents are not required to be posted at the work place Under the MPN Transfer of Care Policy, the MPN Employee Notification Documents are required when transferring an open legacy claim into the MPN Different versions of the MPN End of Coverage notification documents are used: Complete End of MPN Coverage Change to a different MPN with the same provider configuration (ie multiple MPNs change to a single Network Service Entity MPN) All California Employers are still required to adhere to California Regulations pertaining to the DWC-7 posting, Time of Hire Pamphlets, and Predesignation Forms

6 2014 CA MPN Regulations & Legislative Changes/Impacts for Employers New MPN Access Standards for scheduling injured employees medical appointments MPN Contact Definition Change MPN Medical Access Assistant NEW REQUIRED POSITION Changes to the MPN Employee Notification Documents and processes Formal MPN Complaints can be filed against MPNs and employers with the DWC Petitions to Suspend or Revoke an MPN is now allowed if the complaints are not resolved New DWC Random Reviews of MPNs, including MPN Employee Notification Documents New DWC Administrative Hearings for Penalty Scheduling when MPNs have audit citations: MPNs, claim handlers and employers can be fined

7 MPN Definition Changes & Access Standards Section Medical Provider Networks Definitions (20) MPN Contact means an individual(s) designated by the MPN Applicant in the employee notification who is responsible for responding to complaints, for answering employees' questions about the Medical Provider Network and for assisting the employee in arranging for an MPN independent medical review pursuant to Labor Code section (16) Medical Provider Network Medical Access Assistant means an individual in the United States provided by the Medical Provider Network to help injured workers with finding available Medical Provider Network physicians of the injured workers choice and with scheduling provider appointments.

8 MPN Definition Changes & Access Standards Section Access Standards (h) MPN medical access assistants shall be located in the United States and shall be available, at a minimum, from Monday through Saturday from 7 am to 8 pm, Pacific Time, to provide employee assistance with access to medical care under the MPN. The employee assistance shall be available in English and Spanish. The assistance shall include but not be limited to contacting provider offices during regular business hours and scheduling medical appointments for covered employees. Section Employee Notification (A) How to contact the person designated by MPN applicant to be the MPN Contact for covered employees to answer questions about the use of MPNs and to address MPN complaints. The employer or insurer shall provide a toll-free telephone number with access to the MPN Contact if the MPN geographic service area includes more than one area code. A toll-free number must also be listed for MPN Medical Access Assistants, with a description of the access assistance they provide, including finding available MPN physicians of the injured workers choice and scheduling and confirming physician appointments, and the times they are available to assist workers with obtaining access to medical treatment under the MPN;

9 MPN Definition Changes & Access Standards Section Access Standards (f) For non-emergency services, the MPN applicant shall ensure that an appointment for the first treatment visit under the MPN is available within 3 business days of a covered employee s notice to an MPN medical access assistant that treatment is needed. (g) For non-emergency specialist services to treat common injuries experienced by the covered employees based on the type of occupation or industry in which the employee is engaged, the MPN applicant shall ensure that an initial appointment with a specialist in an appropriate referred specialty is available within 20 business days of a covered employee s reasonable requests for an appointment through an MPN medical access assistant. If an MPN medical access assistant is unable to schedule a timely medical appointment with an appropriate specialist within ten business days of an employee s request, the employer shall permit the employee to obtain necessary treatment with an appropriate specialist outside of the MPN.

10 The Importance of the MPN Employee Notification Document The MPN Employee Notification Document is the anchor to serve the injured worker and the compass to navigate around the iceberg of MPN regulations Navigating the SB 863/SB542/AB1422 CA DWC MPN Regulations New MPN Employee Notification MPN Contact Medical Access Assistant MPN Complaints DWC MPN Random Reviews Administrative Penalty Schedule; Hearing Petition to Suspend or Revoke a Medical Provider Network Workers Compensation Appeals Board (WCAB) Rules of Practice & Procedure Potential for Department of Insurance Investigations 10

11 Other California Employers Regulatory Requirements All California Employers are still required to adhere to California Regulations pertaining to the DWC-7 posting, Time of Hire Pamphlets, and Predesigation Forms MPN Regulations Title 8 California Code of Regulations, Chapter 4.5. Division of Workers' Compensation, Subchapter 1. Administrative Director -- Administrative Rules, Article 3.5. Medical Provider Networks: Sections DWC-7 Notice to Employees Poster Injuries Caused by Work The required posted notices are covered under LC 3550 and CCR Time of Hire Pamphlet Facts About Workers Compensation The time of hire pamphlet is covered under LC 3551 and CCR Predesignation of Personal Physicians and Reporting Duties of the Primary Treating Physician Regulations Title 8, California Code of Regulations, Sections 9780, , 9783, , and 9785

12 Fraud Situations & Best Practices When Managing a Network California Assembly Bill 1422 Relates to an automatic stay of lien on a physician or provider of medical services upon filing of criminal charges against them for an offense involve fraud against the workers' compensation system, medical billing fraud, insurance fraud, or fraud against the Medicare or Medi-Cal programs. Makes that automatic stay effective until specified adjudication procedures for the charges have been completed. (source Lexis-Nexis) Best Practices Remove provider(s) from the MPNs; send termination letters, terminate contracts, remove from MPN Internet Sites Where appropriate, send copies of the termination letters to the claim branches Implement denial flags in claims/bill review system Implement MPN Transfer of Care Policy for open/legacy claims Follow the regulations and court decisions pertaining to liens

13 Open Discussion/Questions and Answers