SB 914, as introduced, Mendoza. Workers’ compensation: medical provider networks: independent medical reviews.
Existing law establishes a workers’ compensation system, administered by the Administrative Director of the Division of Workers’ Compensation, to compensate an employee for injuries sustained in the course of his or her employment. Existing law authorizes an insurer, employer, or entity that provides physician network services to establish or modify a medical provider network for the provision of medical treatment to injured employees, and requires the administrative director to contract with individual physicians or an independent medical review organization to perform medical provider network independent medical reviews. Existing law provides that if a treatment or diagnostic service remains disputed after a 3rd physician’s opinion, the injured employee may request a medical provider network independent medical review. Existing law requires the review to use standards established in statute or use the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines.
This bill would delete the authorization to use the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines as standards for those independent medical reviews. The bill would make additional technical, nonsubstantive changes.
Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 4616.4 of the Labor Code is amended to
(a) (1) The administrative director shall contract with
4individual physicians, as described in paragraph (2), or an
5independent medical review organization to perform medical
6provider network (MPN) independent medical reviews pursuant
7to this section.
begin delete physiciansend delete licensed pursuant to Chapter 5
9(commencing with Section 2000) of the Business and Professions
10Code may be MPN independent medical
begin delete reviewers.end delete
11(3) The administrative director shall ensure that
begin delete theend delete MPN
begin delete reviewersend delete or those within the review
13organization shall do all of the following:
14(A) Be appropriately credentialed and privileged.
15(B) Ensure that the reviews provided by the medical
16professionals are timely, clear, and credible, and that reviews are
17monitored for quality on an ongoing basis.
18(C) Ensure that the method of selecting medical professionals
19for individual cases achieves a fair and impartial panel of medical
20professionals who are qualified to render recommendations
21regarding the clinical conditions consistent with the medical
22utilization schedule established pursuant to Section 5307.27.
23(D) Ensure that confidentiality of medical records and the review
24materials, consistent with the requirements of this section and
25applicable state and federal law.
26(E) Ensure the independence of the medical professionals
27retained to perform the reviews through conflict-of-interest policies
28and prohibitions, and ensure adequate screening for conflicts of
begin deleteMedical professionals end deleteselected by
31the administrative director or the independent medical review
32organization to review medical treatment decisions shall be
begin delete physicians,end delete as specified in paragraph (2) of subdivision
begin delete meetend delete the following minimum requirements:
35(A) The medical professional shall be a clinician knowledgeable
36in the treatment of the employee’s medical condition,
37knowledgeable about the proposed treatment, and familiar with
38guidelines and protocols in the area of treatment under review.
P3 1(B) Notwithstanding any other law, the medical professional
2shall hold a nonrestricted license in any state of the United States,
begin delete physicians,end delete a current certification by a
4recognized American medical specialty board in the area or areas
5appropriate to the condition or treatment under review.
6(C) The medical professional shall have no history of
7disciplinary action or sanctions, including, but not limited to, loss
8of staff privileges or participation restrictions taken or pending by
9any hospital, government, or regulatory body.
10(b) If, after the third physician’s opinion, the treatment or
11diagnostic service remains disputed, the injured employee may
12request MPN independent medical review regarding the disputed
13treatment or diagnostic service still in dispute after the third
14physician’s opinion in accordance with Section 4616.3. The
15standard to be utilized for MPN independent medical review
16is identical to that contained in the medical treatment utilization
17schedule established in Section
begin delete 5307.27, or the American College
18of Occupational and Environmental Medicine’s Occupational
19Medicine Practice Guidelines, as appropriate.end delete
begin deleteApplications end deletefor MPN independent
21medical review shall be submitted to the administrative director
22on a one-page form provided by the administrative director entitled
23“MPN Independent Medical Review Application.” The form shall
24contain a signed release from the injured employee, or a person
25authorized pursuant to law to act on behalf of the injured employee,
26authorizing the release of medical and treatment information. The
27injured employee may provide any relevant material or
28documentation with the application. The administrative director
29or the independent medical review organization shall assign the
30MPN independent medical reviewer.
31(d) Following receipt of the application for MPN independent
32medical review, the employer or insurer shall provide the MPN
33independent medical reviewer, assigned pursuant to subdivision
34(c), with all information that was considered in relation to the
35disputed treatment or diagnostic service, including both of the
37(1) A copy of all correspondence from, and received by, any
38treating physician who provided a treatment or diagnostic service
39to the injured employee in connection with the injury.
P4 1(2) A complete and legible copy of all medical records and other
2information used by the physicians in making a decision regarding
3the disputed treatment or diagnostic service.
4(e) Upon receipt of information and documents related to the
5application for MPN independent medical review, the MPN
6independent medical reviewer shall conduct a physical examination
7of the injured employee at the employee’s discretion. The MPN
8independent medical reviewer may order any diagnostic tests
9necessary to make his or her determination regarding medical
10treatment. Utilizing the medical treatment utilization schedule
11established pursuant to Section 5307.27,
begin delete or the American College and taking into
12of Occupational and Environmental Medicine’s Occupational
13Medicine Practice Guidelines, as appropriate,end delete
14account any reports and information provided, the MPN
15independent medical reviewer shall determine whether the disputed
16health care service was consistent with Section 5307.27
begin delete or the
17American College of Occupational and Environmental Medicine’s
18Occupational Medicine Practice Guidelinesend delete
19medical needs of the injured employee.
20(f) The MPN independent medical reviewer shall issue a report
21to the administrative director, in writing, and in layperson’s terms
22to the maximum extent practicable, containing his or her analysis
23and determination whether the disputed health care service was
24consistent with the medical treatment utilization schedule
25established pursuant to Section 5307.27,
begin delete or the American College within 30 days of
26of Occupational and Environmental Medicine’s Occupational
27Medicine Practice Guidelines, as appropriate,end delete
28the examination of the injured employee, or within less time as
29prescribed by the administrative director. If the disputed health
30care service has not been provided and the MPN independent
31medical reviewer certifies in writing that an imminent and serious
32threat to the health of the injured employee may exist, including,
33but not limited to, serious pain, the potential loss of life, limb, or
34major bodily function, or the immediate and serious deterioration
35of the injured employee, the report shall be expedited and rendered
36within three days of the examination by the MPN independent
37medical reviewer. Subject to the approval of the administrative
38director, the deadlines for analyses and determinations involving
39both regular and expedited reviews may be extended by the
P5 1administrative director for up to three days in extraordinary
2circumstances or for good cause.
3(g) The MPN independent medical reviewer’s analysis shall
4cite the injured employee’s medical condition, the relevant
5documents in the record, and the relevant findings associated with
6the documents or any other information submitted to the MPN
7independent medical reviewer in order to support the determination.
8(h) The administrative director shall immediately adopt the
9determination of the MPN independent medical reviewer, and shall
10promptly issue a written decision to the parties.
11(i) If the determination of the MPN independent medical
12reviewer finds that the disputed treatment or diagnostic service is
13consistent with Section
begin delete 5307.27 or the American College of the injured employee may
14Occupational and Environmental Medicine’s Occupational
15Medicine Practice Guidelines,end delete
16seek the disputed treatment or diagnostic service from a physician
17of his or her choice from within or outside the medical provider
18network. Treatment outside the medical provider network shall be
19provided consistent with Section
begin delete 5307.27 or the American College The employer shall be liable for the
20of Occupational and Environmental Medicine’s Occupational
21Practice Guidelines.end delete
22cost of any approved medical treatment in accordance with Section
235307.1 or 5307.11.