The Workers’ Compensation Medical Provider Network (MPN) in a Post

SB863/SB542/AB1422 World

Stephanie Leras

Director, Product Implementation

Coventry

SB863 & SB542Big Changes for MPNs

SB863 MPN Regulations (Effective 8/27/14) • Expansion of MPN applicants

• Four Year Re-approval

• Provider Acknowledgement

• Geocoding

• Provider data requirements

• Expanded MPN URL/MPN directory specifications

• Change to MPN Notifications

• Creation of Medical Access Assistant

• Fines & Penalties

SB542 (Effective 1/1/16)• Added components to requirements of SB863

• change to DWC-7 Form

SB863 & SB542 - Specifics

Created New MPN Applicants

“Entity Providing Physician Network Services”

• Enabled consolidation of duplicate MPNs filed at the carrier/underwriter level

• New streamlined employee notification process of MPN consolidation of duplicate MPNs in lieu of Transfer of Care

• Created new business opportunities for Managed Care Organizations, Third Party Administrators and Networks

SB863 & SB542 - Specifics

MPN 4 Year Re-Approval

Full Application Required

How to calculate:(When in doubt call the DWC Medical Unit)

A. If the MPN application was approved on or after January 1, 2014, the MPN approval expiration is 4 years after the approval date of the MPN application.

B. If the MPN application was approved prior to January 1, 2014, the MPN approval expiration is determined based on the most current MPN material modification approval date that occurred prior to January 1, 2014, or the MPN application approval date.

Please note:

MPN re-approvals must be filed with the DWC 6 months prior to the MPN’s expiration date

MPN cannot add new MPN employers or injured workers when MPN expired

SB863 & SB542 – Specifics

MPN Provider Acknowledgements

• All physicians (includes physicians, surgeons, psychologists, acupuncturists, optometrists, dentists, podiatrists and chiropractors) now required to sign MPN acknowledgements specifying intent to be in MPN

• Requirement may be met via an online form that meets requirements of Civil Code sections 1633.1 et seq SB542

Geocoding in All MPN Applications (including re-approvals)

• Identification of PTP, Urgent Care, Hospital and most commonly used WC specialties within the required 15 or 30 miles radius of center of zip code

SB863 & SB542 – Specifics

Quarterly Provider Outreach/Removal of Providers Within 45 Day Notification

• Removal of providers from the MPN within 45 days notification via the MPN website that the provider is not taking MPN patients

• Quarterly outreach to all MPN providers

Expanded Directory Requirements

• By referral only requirements in MPN directories

• Roster of Treating Physician search displayed in MPN directories. May not include groups, ancillaries or hospitals

• Contact Information for MAA and MPN contact as well as how to get copies of MPN notices and policies included in the directory or a separate informational url

SB863 & SB542 – Specifics

Modifications to Require MPN Employee Notifications and

MPN Cessation Notice

• Complete MPN Employee Notification modified to include:

• MAA and MPN contact information

• Roster of Treating physician link

• MPN Cessation modified

• Includes MPN URL

• Includes MPN Contact and MAA information

• Changes to the MPN Plan Modification form 9767.8

• Key change: no longer required to file a modification due to 10% change in network

• Modification to DWC-7 form (SB542 effective 1/1/16)

SB863 & SB542 – Specifics

MPN Access Assistant (MAA)

Requirements

• MPN regulations require a person available to make medical appointments for an IW Monday – Saturday 7am-8pm via a toll free number

• If the IW gets voicemail, the call must be returned within the next business day

• Call logs must be kept on the MAA activity

• Important note: adjusters may act as MAA’s when answering MAA toll free number

SB863 & SB542 – Specifics

Fines and Penalties for Non-Compliance per MPN Regulations

(Section 9767.19)

• DWC notify MPN applicant in writing of specific violation

• Administrative Director shall allow the MPN applicant an opportunity to correct the violation or to respond within ten days with a plan of action to correct the violation in a timely manner

• If AD determines that the violation has not been cured in a timely manner, they will issue a Notice of Action to the MPN applicant that specifies the time period in which the administrative penalty (sent by US Mail)

• Penalty amounts may be mitigated upon written request to the Administrative Director by the MPN applicant within twenty-one days of the date of the Notice of Action

Ensure the Following Regulatory Requirements

are in Place Before Filing an MPN

SB863 & SB542 - What to do Before Filing

MPN informational URL including how to contact your MAA, MPN Contact and get MPN notices/policies upon request

MPN complete state directory url, including by referral only indicator and roster of treating physicians search

Medical Access Assistant service operational and number made available to injured workers

Ensure all DWC-7 postings were updated per the new form as of 1/1/16

Make sure new state reporting requirements in place with bill review vendor (effective 4/6/16)

Know the date of your re-application filing or ask the DWC

AB1244 (1/1/17) & AB1422 - Provider Fraud

Automatic Stay of Liens • Labor Code 4615: Liens filed by physicians or providers who are criminally charged with workers’

compensation fraud, medical billing fraud, insurance fraud, and Medicare or Medi-Cal fraud automatically stayed pending the disposition of criminal case.

Provider Suspension • Labor Code 139.21 Convicted of any felony or misdemeanor that involves fraud or abuse of Medi-

Cal, Medicare, or workers compensation system, or fraud or abuse of any patient; license revoked

or suspended; or suspended due to fraud or abuse from Medicare or Medicaid programs

Actions for MPNs:• Monitor DWC posted lists of lien stayed & suspended providers,

• Take appropriate actions to stay payment of liens and/or remove providers from the MPN network as required.

Stephanie LerasDirector, Product Implementation

CoventryLerasS@aetna.com

Thank You