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A series of articles emphasizing practical
knowledge you can't find in practice guides
and interviews with experts who share
their techniques for effective and efficient
case management
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Articles emphasizing practical knowledge you
can't find in practice guides
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Profiles of people who changed workers’
compensation law.
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• Warren
Schneider
• Marjory Harris
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In the second article in a series of editorials
on “Workers’ Compensation Disabled:
What Went Wrong on the Road to Reform?” we explore the medical
provider network (MPN) and how to find the best doctors
and improve the worst. We provide
a search method, sample questions, and a downloadable
spreadsheet you can
use to store the fruits of your labors in the MPN labyrinth.
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Like the last set of reforms in 1989, SB 899, signed
into law on April 19, 2004, was meant to reduce
medical treatment costs. Labor Code §4616
provided for the establishment of medical provider
networks (MPNs) to allow insurers or employers to
control treatment by requiring injured workers to get
treatment from preselected physicians, clinics,
hospitals, and other health professionals. It was
assumed that this would control the cost of treatment,
as would mandated treatment guidelines and
utilization review. Only time will tell, as similar past
assumptions underlying the reform law of 1989
ultimately proved erroneous.
In this article we discuss some problems inherent in
the new system, and some ways to get the best from
the MPNs or at least to avoid the worst.
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Labor
Code §4616,
in relevant part
(a) (1) On or after January 1, 2005, an insurer or employer
may establish or modify a medical provider network for
the provision of medical treatment to injured employees.
The network shall include
physicians primarily engaged in the treatment of occupational
injuries and physicians primarily engaged in the treatment
of nonoccupational injuries. The goal shall be at least
25 percent of physicians primarily engaged in the treatment
of nonoccupational injuries. The administrative director
shall encourage the integration of occupational and nonoccupational
providers. The
number of physicians in the medical provider network shall
be sufficient to enable treatment for injuries or conditions
to be provided in a timely manner. The provider network
shall include an adequate number and type of physicians,
as described in Section 3209.3, or other providers, as
described in Section 3209.5, 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.
For
the entire statute, click here
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Control
of medical treatment has been the employers’ holy grail
One would think that employers would be happy
being allowed to exclude doctors who they
considered “abusive” by overtreating and never
finding workers to have reached “maximum medical
improvement,” and by having the restrictions
imposed by the mandated guidelines and utilization
review. But no, they want more. They want “provider
profiling,” to weed out of the MPNs those doctors
whose treatment costs exceed others. There are
computer programs available to accomplish this
lofty goal and scare the network docs into
underprescribing.
The zeal to limit costs by imposition of rigid
guidelines and utilization review by non-examining
doctors who question routine recommendations, and
the low fees, combined with constant report writing
and the arcane AMA Guides, have driven many
doctors from the system. Indeed, with the diminishing
QME lists and failure of treating doctors to write
adequate ratable reports, the system may come to a
grinding near halt that may make the present chaos
seem paradisiacal.
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§4616
(c) Physician compensation may not be structured
in order to achieve the goal of reducing, delaying, or
denying medical treatment or restricting access to medical
treatment.
Labor Code §4616.1,
in relevant part
a) An insurer or employer that offers a medical provider
network under this division and that uses economic profiling
shall file with the administrative director a description
of any policies and procedures related to economic profiling
utilized by the insurer or employer. The filing shall
describe how these policies and procedures are used in
utilization review, peer review, incentive and penalty
programs, and in provider retention and termination
decisions. The insurer or employer shall provide a copy
of the filing to an individual physician, provider, medical
group, or individual practice association.
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The
Case of the Disappearing Doctor
One of the problems plaguing the new network
system is the disappearing doc. The injured worker
calls for an appointment and learns the doctor does
not take workers’ compensation cases, or is no
longer in practice. Some networks are populated by
“phantom docs” who had no idea they were even on
the network. They belong to Blue Cross or some
other preferred provider organization (PPO) that got
included in the MPN.
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California
Medical Association’s Survey of Physicians: physicians
filled with despair
A common complaint: MPNs are “nothing more than
middlemen stealing money from the system. The majority
are taking 15% of what the state is paying for doing
nothing. This money has been taken directly out of the
physician’s pocket. End result is that the system
is now asking doctors to do the same work they did last
year for less money. More documentation is required
and more hassle is required to get paid….”
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Blowback
At some point the cost of maintaining and controlling
the networks may prove unwieldy and unprofitable.
Litigation is inevitable.
A more likely problem is the difficulty of controlling
medical doctors, who are generally an autonomous
group geared to small practice rather than big
bureaucracy. It may prove to be like herding cats.
Established practitioners balk at having to cite
chapter and verse from Wheeless when requesting
authorization for shoulder surgery to repair a torn
rotator cuff. Being sent pages from ACOEM on
treatment of the shoulder by a nurse employed by a
peer review outfit raises hackles of Board certified
orthopedic surgeons. While some may flee treatment
of workers’ compensation injuries, the sheer
economics of medicine as practiced today will dictate
that most doctors will stay and cope.
When polled, most Californians want the right to
choose their own doctor. The right to choose the
treating doctor was a hard fought battle that is not
over. Resentment over perceived substandard care
may boil over into legislative changes as the reforms
are perceived as grossly unfair by more and more
people.
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The
Administrative Director announced the planned advent of
an online complaint form so that abuses of the MPN system
can be reported in some standardized way, as we can now
do with complaints concerning utilization review.
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Two
Recent Experiences Walking in the
MPN Labyrinth
In the first, I was told that the doctor I had elected
was not on the network. I was given a telephone
number where, my opponent said, I would receive
assistance in picking a network doctor for my client.
When I finally got someone to pick up my call, I was
informed that the two doctors whose last names I
spelled out were not on the network. I then asked for
the URL so I could search myself. I was given a
string of 9 consonants with no vowels. It took quite
a while to get this man to spell out the name of the
website (http://www.bclhwcmcs.com/)
so that I could
get the letters right. From his accent, I believe that I
was speaking to someone in India. I finally got him to
pronounce the letters by using words (“B” as in
boy,
“C” as in child, etc.) Eventually, I was able to
find the
provider finder for California where I found that both
of the doctors I had inquired about were listed as
MPN providers.
At a later date, I had to repeat these steps to look for
a treater in another specialty on the same MPN. I no
longer had the data from the search I made, as I was
on vacation at that time working on a laptop. This
time, I was routed to a number of different people
before I found someone who told me there was no
way I could access the network over the internet, but
that she would send me a list after she accessed
the network over her intranet. Her list did not include
either one of these providers I had previously
confirmed were on the MPN. However, later she
sent me a link to the website I had previously been directed
to (with 9 consonants). Lo and behold, there
were the same two names from before and a much
bigger list than the one that she had sent me.
In a second experience, my client
moved to Hawaii.
I was sent a list of doctors that the adjuster thought
were suitable. I called all the doctors and learned
that they would not take California workers’
compensation cases. Several told me they do not
take Hawaiian workers’ compensation cases either.
I got the names of the office managers and had them
confirm that they would not accept my client for
treatment. I then found, on the same MPN, a doctor
in California who also has an office in Hawaii.
I elected treatment for my client with this doctor,
noting that since he was on their MPN in California,
there was no reason he could not see my client in
Hawaii. I was then contacted by opposing counsel,
who told me that the claims adjuster was unable to
locate the doctor on the California MPN, that his
name did not appear in the printed directory, and
how did I find him? I sent a PDF file of the webpage
and all was well.
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| In my
dealings with medical provider networks (MPNs), the labyrinth
comes to mind. Not the meditation aid popular today, which
relaxes the body and lifts the spirits,
but the maze of Greek myth
that is confusing, tedious and frustrating. |
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Lessons
Learned in the Labyrinth
From these experiences I learned
two lessons:
1) don't rely on the adjuster or anyone affiliated with
the network to provide names or confirmations and
2) do the research yourself. It is not likely your client
has the know-how, drive or stamina to get through
the maze unaided. Even though it's time consuming,
by storing the results, you do not need to reinvent the
wheel each time. I have also learned that many
doctors do not know which MPNs they are on, so that
calling the doctors I favor has not worked as well as
the process in the sidebar.
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How
to Find the
Best Doctors
1) Get the URL or web address for the MPN. Sometimes this
is provided in a letter to the injured worker, but I have
seen URLs in such letters that simply do not turn up anything.
If you cannot find this in materials sent to the injured
worker, you can search on line. For example, if you Google
“SCIF MPN,” this
link turns up. While this is not exactly
where you want to be, by eliminating the “SiteHelp.asp”
part of the URL, you get to
http://www.geoaccess.com/
SCIF/po/, where you can then begin
your search. Whenever I find a place I want to start from,
I save it to a spreadsheet (see “How to Save Your
Searches” below).
2) Once you are in the provider database, you can usually
search by name, or specialty, or by geographical area.
If you want to find all the orthopedic surgeons within
15 miles of your client's zip code, you can do this in
a few clicks. Or you can search for specific names on
most of the MPNs.
3) Once you find a doctor you think would be good, you
need to call that doctor's office to see if he or she
is accepting workers’ compensation cases. Many of
those listed may not be available to treat, or may not
be able to schedule within a month of your call. It is
important to take notes of who you spoke to and where,
and what they said about availability. If there is not
an adequate choice, you may be able to avoid the network
altogether.
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How
to Save Your Searches
1) There is no need to repeatedly trudge through
the same labyrinth. Save your searches in the
downloadable Excel spreadsheet. Enter the name
of the insurer or adjusting agency in the “MPN”
column, and add the hyperlink in the “LINK” column.
I store the password, if any, next to the MPN name
in parentheses. You can attach notes and phone
numbers to your spreadsheet, and you might want to
save the names of favorite doctors you find on
particular MPNs.
2) It is a good idea to save notes from your search
to your client’s electronic file or case management
database as well. If something turns up that could
apply to another client, this is a good time to save
the information in that client’s records, rather than
retracing your steps later.
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Getting
the Best from the Worst
While in denied cases you will automatically
be out
of the MPN system, it will take a lot of litigation to get
out of the MPN system in an admitted case. If you
have the opportunity to pick good treating physicians,
preferably ones who are also Qualified Medical
Evaluators, you will have access to the reports you
need and will be able to overcome the deficiencies
of the panel QME process. The problem arises
where there is no one available on the MPN you
can rely on for decent treatment or useful evidence.
You may be dealing with doctors who take a dim
view of injured workers, hate the AMA Guides and
refuse to do ratable reports, or simply do not know
much about the workers’ compensation law.
Whether mean-spirited or unknowledgeable, these
doctors may inflict unnecessary harm unless we put
effort into drawing out their better qualities.
It has been my experience with medical doctors,
which began many years ago when I was a child, that
they are very intelligent and diligent at learning. Most
of them also do believe in primum non nocere, “first
do no harm” (which is not part of the Hippocratic
oath – see http://en.wikipedia.org/wiki/Hippocratic_Oath.)
They also believe in protecting their licenses so that
they can continue in their chosen career, which, while
not as lucrative as it was in the past, still pays better
than claims adjusting.
One needs to appeal to these interests in drawing
out the best of care in a system where doctors feel
thwarted in their efforts to treat, limited by guidelines
that may appear absurd and requirements for
justification of routine procedures and ridiculous
denials of care under utilization review. At right are
some approaches that may prove beneficial:
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1. Help
the doctor by conducting some preliminary medical research.
See the end of the first article in this series, Do-It-Yourself
Medical Research You can then send
this to the doctor by letter or email and suggest he include
it with his treatment requests.
2. Remind the doctor of his ethical and legal responsibilities.
It is important to word such reminders as tactfully as
possible, to avoid ego issues. Like lawyers, doctors are
aware they have a fiduciary duty towards their patients.
Comments such as “In order to fulfill professional
and fiduciary obligations towards IW, I would request
that you continue care until such time as blah blah”
will be more helpful in the long run than accusations
of patient abandonment. Likewise with suggested treatments
to avoid malpractice claims or disciplinary proceedings.
3. Ask the doctor whether he would recommend any different
treatments if he were seeing the patient under a private
medical plan not subject to “MTUS” (the euphemism
for ACOEM plus other guidelines). This is more tactful
than suggesting that the doctor is using a lower standard
of care in treating the injured worker than required for
other patients. Such an approach is a reminder that the
standard of care is a professional standard that should
be applied no matter what compensation is offered. One
could also ask the doctor whether he or she recommends
that the injured worker seek certain treatments outside
the MTUS in order to avoid long term harm. In certain
cases, hopefully very few or even none, one will have
to spend time on crafting a tactful approach to insisting
on better treatment for the client. If the treater is
not willing to provide care up to the standard in effect
for non-industrial patients, it
is time to transfer care and, if necessary, find
other treatment resources.
4. Make sure the doctor complies with the California pain
law, which for patients is in Health
and Safety Code Sec. 124960 and 124961
and for doctors is in Business
and Professions Code Sec. 2241.5.
Transfer care to a pain specialist whenever necessary
and, if there are none or the only one available does
not seem to be addressing the pain issues adequately,
ask if the doctor believes the patient has intractable
pain. If so, ask the doctor if he is in compliance with
the pain law and if not, why not. If he or she claims
the workers’ compensation law prevents adequate
pain control, consider filing complaints with various
state agencies.
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