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Medical Provider Networks - FAQ's
June, 19 2012

What is a Medical Provider Network (MPN)? In 2004, the legislature approved SB 899, which allows for the establishment of MPNs to treat work injuries and illnesses on or after January 1, 2005. A MPN is an entity or group of health care providers set up by an insurer or self-insured employer and approved by the Division of Workers' Compensation Administrative Director to treat injured workers. Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs are required to meet "access to care" standards for common occupational injuries and work-related illnesses.

 

What is the advantage of using a MPN for medical treatment? The biggest advantage is that it allows Republic Indemnity to have medical control for the life of the claim, enabling us to manage the type and frequency of medical treatment more effectively than in the past. By applying evidence based treatment standards (as defined by the Division of Workers’ Compensation Administrative Director) coupled with the contracting of medical providers, treatment abuses can be minimized, costs can be reduced, and treatment outcomes can be improved. In a number of claims, both the duration of temporary disability and amount of residual permanent impairment can be reduced as well.

 

When will Republic Indemnity’s MPN be approved? Our MPN has been approved by the State of California’s Department of Industrial Relations, Division of Workers’ Compensation and is in force for all new and renewal policies with an effective date on/after July 1, 2012.

 

What is the name of Republic Indemnity’s MPN? Our network is called the Republic Indemnity Company Medical Provider Network, and was developed in association with Kaiser On-the-Job (KOJ) and Networks by Design (NBD).

 

Why is Republic Indemnity partnering with Networks by Design (NBD)? Networks by Design is a new California PPO company designed to provide medical networks that are customized to the needs of each individual client. Benefits of the NBD program include requiring payer approval to physicians before they are able to prescribe certain classes of medications; limits on the filing of liens relating to treatment from network providers; and provider performance reviews that help ensure compliance with evidence based treatment guidelines, improve ultimate outcomes, and reduce the need for costly Utilization Review.

 

Why is Republic Indemnity partnering with Kaiser On-The-Job? Kaiser On-The-Job is a coordinated program distinguished by consistent quality management, direct communication with claims administrators, and advanced reporting capabilities. Features of their program include the presence of occupational health care centers located near clinical facilities that offer convenient access to specialists, pharmacies, and physical therapy; experienced occupational health physicians that will examine your injured workers and determine treatment according to standard clinical guidelines; and the ability to work closely with our claims staff to facilitate and coordinate a prompt return to work for injured employees.

 

How do I find the name of a MPN provider? To obtain the name of a provider in the Republic Indemnity Company Medical Provider Network, you can call toll free (877) 854-3353 or access our online provider directory at www.talispoint.com/ri.

 

What if the employer does not use the MPN? If medical treatment has been initiated with a non-MPN provider on a new claim, the employer should immediately contact their Republic Indemnity claims adjuster.

 

Does using the MPN result in premium savings? Republic Indemnity's premium rates are based on the assumption that each employer will use the MPN for all new claims. In the long run, we expect that taking advantage of the MPN will result in lower claim costs and premiums for employers.

 

If the employer offers a group health plan to its employees, how does that affect the MPN? Occupational injuries will be treated by the Republic Indemnity Company Medical Provider Network. Non-occupational illnesses and medical treatment will continue to be provided through applicable group health medical providers.

 

Can an employee pre-designate a physician prior to an industrial injury? Yes, but only if the employer offers non-occupational group health coverage, the doctor (MD/DO) selected is the employee’s regular physician and agrees to treat him/her for work injuries or illnesses, and the employee gives the employer notice in writing prior to the industrial injury.

 

Will small employers use the MPN for their employees? The MPN applies to all employees regardless of the size of the employer.

 

How do I find out if a provider is a member of the MPN? Call the Republic Indemnity Company MPN at (877) 854-3353 or access the provider directory at www.talispoint.com/ri.

 

What about employers using a local clinic that is not in the MPN? If the current industrial clinic or provider used is not a member of the MPN, the employer is required to locate and refer injured workers to a local MPN clinic/provider. If the local provider is interested in becoming part of the NBD network, they may call them at (877) 854-3353. Kaiser limits its contracting with providers, and at this time it is unknown if they will accept any additions.

 

What happens if an employee is injured? The employer must immediately provide the injured worker a "Notification of Rights Pamphlet," which explains the Medical Provider Network process and the Employee Claim Form, DWC-1. The Notification of Rights pamphlet, provided in English and Spanish, is included in our Claims Kit, and additional copies may be ordered from Republic Indemnity by faxing the request to our Mail/Supply Department at (818) 382-1297. At the time of a work injury, refer the covered employee to a Republic Indemnity Company MPN Provider and immediately report the claim to Republic Indemnity. We have developed an easy-to-use input screen for California policyholders to complete and electronically transmit the claim report via the Internet at www.republicindemnity.com. As a secondary option, contact our Claims Department between the hours of 7:00 a.m. and 5:30 p.m., or call our after-hours/weekend call center at (888) 336-7569.

 

If the injury requires emergency care? The injured worker should be referred to the nearest appropriate medical facility/provider regardless of whether or not they are a member of our MPN.

 

An employee had an injury last year; will the employee be in the MPN? Republic Indemnity will be handling these cases on an individual basis. Depending on the circumstances of the individual, the employee may or may not be transferred to a MPN physician.

 

If the employee is transferred to a new physician in the MPN, what happens if he/she doesn't like the physician? The employee may transfer to or seek the opinion of another physician in the MPN.

 

What if an employee disputes the medical treatment provided in the MPN? Independent Medical Review is a process provided for in the MPN for employees who continue to dispute the diagnosis or the medical treatment they are receiving after obtaining a second or third opinion within the network. They may appeal to an Independent Medical Reviewer appointed by the Administrative Director, who will review their case and issue an opinion on the appropriateness of the treatment compared to the utilization guidelines.

 

I have heard that the employer's insurance company is responsible for paying medical bills for new claims in which injury is being disputed. Who is responsible for any financial liability? Under the new law, an insured employer's insurance company is responsible for adjusting/paying medical bills up to $10,000 or until the claim is accepted or denied. There may be certain exceptions when this would not apply, such as a dispute over employment status or coverage, and affirmative defenses such as intoxication, self-inflicted injury, suicide, initial physical aggressor, off-duty recreational duties, conviction of a felony, post-termination injury, horseplay, etc. This is why it is so important to immediately report any injury claim and refer the employee to an MPN provider since the "clock starts ticking" as soon as the employee files the Employee Claim Form, DWC-1.

 

Whom do I call for further information? Republic Indemnity has expended considerable time and effort training our staff on MPN. All of our claims adjusters have the knowledge and resources to help with any questions, or you may contact the following Division Claims Specialists:

 

Southern California

Carla Nelson

818-382-1220

Northern California

Matt Sheldon

415-954-1006

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