The California Department of Industrial Relations, Division of Workers’ Compensation (DWC) has received approval of emergency regulations that provide injured workers whose care is being managed by a medical provider network (MPN) with a way to receive an independent review of their diagnosis and treatment. The emergency regulations became effective Jan. 1, 2005.
“MPNs ease access to treatment for workers because they bring diverse care providers under one roof,” said DWC Administrative Director Andrea Hoch. “And the independent medical review regulations ensure workers have the opportunity to seek an opinion from a doctor outside the network.”
When receiving care through an MPN, an injured employee can seek a second and third opinion from physicians within the MPN if the employee disputes the diagnosis, diagnostic service(s) or medical treatment of the treating physician. If the dispute is not resolved after the third opinion, the injured worker may seek an independent medical review (IMR) from a physician under contract with the DWC’s administrative director.
The IMR regulations establish the criteria and process by which DWC contracts with individual physicians and establishes a statewide list of eligible independent medical reviewers.
“Physicians who meet the criteria for independent medical reviewer are strongly encouraged to apply,” said Hoch. “The physician contract application form is included in the DWC’s new regulations.”
To qualify for the administrative director’s list of independent medical reviewers a physician must complete the DWC’s contract application form and demonstrate they are: board certified; have an unrestricted license; are not currently accused of violating quality care standards, fraud or felony related to medical practice; have not been terminated or disciplined by the DWC Medical Unit or administrative director in relation to their role as a qualified medical examiner; have not been convicted of a felony crime or a crime related to the conduct of medical practice; and have had no history of disciplinary action or sanction.
In addition to the physician application process, the new regulations lay out the way in which an injured employee requests an IMR, which could involve an in-person examination or records review. After the examination or records review, the independent medical reviewer must issue a report to the administrative director with analysis and a determination whether the disputed diagnostic service(s) or medical treatment was consistent with the medical treatment utilization schedule adopted by the administrative director.
If the independent medical reviewer agrees with the diagnostic service or medical treatment prescribed by the treating physician, the injured employee must continue to receive medical treatment within the MPN. If the independent medical reviewer does not agree, the injured employee can seek diagnostic service or medical treatment from a physician of his or her choice within or outside the MPN.
The form eligible injured workers will use to request an IMR is part of the regulations adopted by the DWC. MPN administrators must provide this request form to injured workers wishing to request an IMR.
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