CANS ALERT #1
January
2005
Work Comp Medical Provider Network (MPN) Contracts
The new Comp laws that went into effect 1/1/05 allow
employers and Comp insurers to create MPNs that employees injured after that
date must use to receive
medical care.
Employers and insurers don’t have to create these MPNs
and if they don’t, then the injured worker can choose any treating physician
after 30 days of directed care as most all did previously.
It is anticipated that most employers and/or their comp insurers will
create such MPNs or contract with an MPN created by others.
The expressed goal of these MPNs is to bring together experienced, knowledgeable
physicians to deliver effective treatment with improved outcomes thus reducing
overall costs. The immediate goal we
will experience will be to get physicians to discount their fees.
Of note is the requirement of a MPN specialist to see any
non-emergent patient referred by other members of the MPN within 20 days.
It is estimated that neurosurgeons not part of an MPN will
experience a sharp reduction in access to these patients.
The MPNs are likely to contact neurosurgeons offering a
contract to become a member of the MPN. These
contracts must be very carefully read and considered as they may contain
certain provisions potentially harmful to your practice.
The first provision to watch for is a % reduction in your
surgical fees as determined by the Work Comp Official Medical Fee Schedule.
Each neurosurgeon needs to decide if he/she wants to discount fees but
realize that such a reduction does not guarantee you will see any patients,
it only guarantees to reduce your compensation in caring for these often
difficult patients and the extensive administrative requirements their care
generates.
Another problematic provision is one in which the MPN can
“sell” your agreement to other MPNs thus creating what is called a “Silent
PPO” into which you will be cast almost always without your knowledge.
If you allow such a “sale”, you will have to extend the discount you
agreed to with the original MPN to any other MPNs into which you are put.
You should know that any other MPNs into which you might be
put via the contract provision to sell your agreement have to honor the %
reduction agreed to in the original contract you signed.
These other MPNs cannot impose their potentially lesser pay scale upon
you. Also, should you have a
contract with these other MPNs to treat non-workcomp patients at some discount,
that contract cannot be enforced upon you when it comes to treating work comp
patients. For instance, it is my
understanding that SCIF has contracted with the Blue Cross Prudent Buyer (BCPB)
plan to be their MPN. If you already
have a contract with BCPB for non-workcomp patients for some crummy % of
Medicare, they can’t force you to honor that contract when caring for work
comp patients.
It’s a jungle out there.
Watch your back.
Randy Smith, M.D.
Editor, CANS Newsletter
1-27-05
More detailed information
about MPNs and Silent PPOs is available from the CMA in their CMA ON-CALL
documents #1907 (Silent PPO) and # 1932 (MPN).
These documents are free to CMA members but are $2 a page to non-members.
I recommend you get #1907 and cough up the $62 for this 31 page document
if you have to. (www.cmanet.org then click
on CMA ON-CALL then Workers Compensation)
The above comments are my
own and generated from what I think I heard during the Workers’ Compensation
session at the CANS meeting on