A few issues have resulted from the 2004 Workers’ Compensation Reform package from Senate Bill 899. Although the creation of Medical Provider Networks (MPNs) has allowed employers to have better control over treatment for injured workers, employers are concerned that these employees are being given permission to get medical care outside of their MPN. These regulatory breaches are defeating the purpose of SB 899.
Additionally, injured workers are frustrated when they have difficulty scheduling appointments with MPN physicians. Many MPN lists contain physicians who are no longer available or who refuse to treat industrial injuries.
Proposed Changes to MPNs – Senate Bill 863
There are minimal changes proposed for applicants in SB 863. It suggests that an entity that provides physician network services can now also apply to be an MPN applicant.
For established MPNs, substantial changes were suggested.
- As of January 1, 2013, a contracting agent must inform MPN providers entering or renewing a provider contract that they are part of an MPN whether their contract is sold, leased, transferred or conveyed to another MPN applicant, contracting agent or WC insurer.
- Medical Access Assistants are required for each MPN to assist workers with finding available MPN physicians and contact physician offices for appointments, and must be available from 7 am-8 pm Pacific Standard Time from Monday through Saturday through a toll-free number.
- 4-Year Approval: MPN plans will be approved for four years, as of Jan. 1, 2014.
- Applications for re-approval of existing plans must be submitted six months prior to four-year approval expiration
- Geocoding of provider listings is required for re-approval
- Quality Assurance processes must be established for MPNs
- MPN physicians need to acknowledge that they elect to be part of the MPN, as of January 1, 2014.
- Each MPN will need to have a website and access to their provider listing on their website as of January 1, 2014:
- The provider listing must be updated quarterly
- The Administrative Director will post website addresses for approved MPNs
Administrative oversight changes would include:
- The Administrative Director can conduct random audits and investigations of MPNs.
- The Administrative Director can impose penalties, probation, suspension or revocation with the right to appeal to the WCAB Reconsideration Unit.
- Any person contending that a MPN is not validly constituted may petition the Administrative Director to suspend or revoke the approval of an MPN.
It remains to be seen whether the amendments made to the MPN process by SB 863 will alleviate the issues created from SB 899. However, the WCAB has been quite rigorous in reversing judges who fail to adhere to the new requirement that a violation in MPN regulation must result in a “denial of medical care” in order to allow the injured worker to seek medical care outside of an employer’s MPN.
You can find the comprehensive regulations for MPN’s in Title 8, California Code of Regulations, sections 9767.1 – 9767.16.
If you have questions about SB 863, please contact the Division of Workers’ Compensation (DWC) with the California Department of Industrial Relations, please review their FAQs page or email them at [email protected].