Workers' compensation regulations governing medical provider networks ready for adoption by November 1 deadline
On Friday, October 22, 2004, the California Division of Workers' Compensation (DWC) filed with the Office of Administrative Law the first set of regulations implementing SB 899, the workers' compensation reforms passed by the Legislature and signed by Governor Schwarzenegger last April.
The regulations, which form the cornerstone of the reform effort, govern the medical treatment component of the workers' compensation system and are designed to improve the treatment process for injured workers by governing the creation and operations of Medical Provider Networks.
"In developing these regulations, the Division of Workers' Compensation collaborated with a large and diverse advisory group," said Andrea Hoch who, as the Division's Administrative Director, coordinated the advisory meetings. "I am very pleased at the work of the advisory group and grateful for the comments by the public which allowed us to move forward with a comprehensive set of regulations."
A Medical Provider Network (MPN) is an entity or group of providers, set up by an insurer or self-insured employer and approved by the administrative director of the Division of Workers' Compensation, to treat workers who are injured on the job. Each MPN must include a mix of doctors who specialize in treating work-related injuries and doctors with general areas of medical expertise and they are required to meet certain access standards to care for common occupational injuries and work-related illnesses. Further, the regulations require MPNs to follow all medical treatment guidelines established by DWC and must allow employees a choice of provider(s) in the network after the first visit. MPNs also must offer an opportunity for second and third opinions if the injured worker disagrees with the diagnosis or treatment offered by the treating physician.
"One of the biggest frustrations for injured workers has been the delays they encountered in obtaining effective treatment approved by the insurers," Hoch said. "MPNs are predicted to minimize these delays because insurer objections to proposed treatments will be reduced, as insurers will have more confidence that MPN doctors are following appropriate medical treatment guidelines."
To ensure that injured workers have easy access to treatment, the regulations require MPNs in urban areas to ensure that a primary care physician and a hospital for emergency care are located within 30 minutes or 15 miles of each employee's residence or workplace. Specialists must be within 60 minutes or 30 miles. Alternate standards for rural areas must be approved by the administrative director of DWC on a case-by-case basis.
The regulations provide safeguards for workers injured prior to the establishment of approved MPNs by allowing them to continue to receive treatment from their existing doctor(s) if the worker is scheduled for surgery, or the worker's condition is acute, serious and chronic, or terminal.
Self-insured employers and insurers may obtain information about the application process to establish an MPN by emailing the Division of Workers' Compensation at email@example.com. Properly completed applications will be processed within 60 days.
The regulations were filed today in order to meet the statutory
deadline of November 1, 2004. The Office of Administrative Law has 10 days
to adopt these regulations on an "emergency" basis. Permanent regulations
must be filed within 120 days of adoption.