Medical Provider Networks

Division 4, Part 2, Chapter 2, Article 2.3 of the Labor Code deals with medical provider networks under the California workers’ compensation laws.

Section 4616 provides that an insurer, employer, or entity that provides physician network services may establish or modify a medical provider network for the provision of medical treatment to injured employees. The network is required to include physicians primarily engaged in the treatment of occupational injuries. The administrative director must encourage the integration of occupational and nonoccupational providers.

The number of physicians in the medical provider network is required to be sufficient to enable treatment for injuries or conditions to be provided in a timely manner. The provider network must also include an adequate number and type of physicians or other providers in order to treat common injuries experienced by injured employees based on the type of occupation or industry in which the employee is engaged, and the geographic area where the employees are employed.

Medical treatment for injuries must be readily available at reasonable times to all employees. To the extent feasible, all medical treatment for injuries are required to be readily accessible to all employees. The administrative director has to consider the needs of rural areas, specifically those in which health facilities are located at least 30 miles apart and areas in which there is a health care shortage.

Every medical provider network is required to post on its internet website a roster of all participating providers, which includes all physicians and ancillary service providers in the medical provider network, and must update the roster at least quarterly. Every network also has to provide to the administrative director the internet website address of the network and of its roster of participating providers. The roster must contain specified information.

Section 4616.1 requires an insurer, employer, or entity that provides physician network services that offers a medical provider network under this division and that uses economic profiling to file with the administrative director a description of any policies and procedures related to economic filing utilized. The filing has to contain specified information.

The administrative director is required to make each approved medical provider network economic profiling policy filing available to the public upon request. The administrative director may not publicly disclose any information submitted pursuant to this section that is determined by the administrative director to be confidential pursuant to state or federal law. The term “economic profiling” is defined.

Section 4616.2 requires a medical provider network to file a written continuity of care policy with the administrative director. The medical provider network must provide all employees entering the workers’ compensation system notice of the medical provider network’s written continuity of care policy and information regarding the process for an employee to request a review under the policy. At the request of an injured employee, completion of treatment must be provided by a terminated provider as set forth in this section.

Section 4616.3 provides that, if the injured employee notifies the employer of the injury or files a claim for workers’ compensation with the employer, the employer is required to arrange an initial medical evaluation and begin treatment as required by Slaw. The employer has to notify the employee of the existence of the medical provider network established, the employee’s right to change treating physicians within the network after the first visit, and the method by which the list of participating providers may be accessed by the employee.

If an injured employee disputes either the diagnosis or the treatment prescribed by the treating physician, the employee may seek the opinion of another physician in the medical provider network. If the injured employee disputes the diagnosis or treatment prescribed by the second physician, the employee may seek the opinion of a third physician in the medical provider network.

Section 4616.4 requires the administrative director to contract with individual physicians, or an independent medical review organization to perform medical provider network (MPN) independent medical reviews pursuant to this section. Only a physician licensed pursuant to Chapter 5 of the Business and Professions Code may be an MPN independent medical reviewer. The administrative director must ensure that an MPN independent medical reviewer or those within the review organization shall do all of the specified actions.

A medical professional selected by the administrative director or the independent medical review organization to review medical treatment decisions is required to be a physician who meets the specified minimum requirements. An application for an MPN independent medical review is submitted to the administrative director on a one-page form provided by the administrative director entitled “MPN Independent Medical Review Application.”

Section 4616.5 defines the terms “employer,” “entity that provides physician network services,” and “entity that provides ancillary services.”

Section 4616.6 states that no additional examinations are to be ordered by the appeals board and no other reports are admissable to resolve any controversy arising out of this article.

Section 4616.7 requires a health care organization to be deemed approved pursuant to this article if the requirements of this article are met, as determined by the administrative director.