SECTIONS 4616-4616.7 - California Statutes

LABOR CODE

SECTION 4616-4616.7

4616. (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.
(2) Medical treatment for injuries shall be readily available at
reasonable times to all employees. To the extent feasible, all
medical treatment for injuries shall be readily accessible to all
employees. With respect to availability and accessibility of
treatment, the administrative director shall consider the needs of
rural areas, specifically those in which health facilities are
located at least 30 miles apart.
(b) The employer or insurer shall submit a plan for the medical
provider network to the administrative director for approval. The
administrative director shall approve the plan if he or she
determines that the plan meets the requirements of this section. If
the administrative director does not act on the plan within 60 days
of submitting the plan, it shall be deemed approved.
(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.
(d) If the employer or insurer meets the requirements of this
section, the administrative director may not withhold approval or
disapprove an employer's or insurer's medical provider network based
solely on the selection of providers. In developing a medical
provider network, an employer or insurer shall have the exclusive
right to determine the members of their network.
(e) All treatment provided shall be provided in accordance with
the medical treatment utilization schedule established pursuant to
Section 5307.27 or the American College of Occupational Medicine's
Occupational Medicine Practice Guidelines, as appropriate.
(f) No person other than a licensed physician who is competent to
evaluate the specific clinical issues involved in the medical
treatment services, when these services are within the scope of the
physician's practice, may modify, delay, or deny requests for
authorization of medical treatment.
(g) On or before November 1, 2004, the administrative director, in
consultation with the Department of Managed Health Care, shall adopt
regulations implementing this article. The administrative director
shall develop regulations that establish procedures for purposes of
making medical provider network modifications.

4616.1. (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.
(b) The administrative director shall make each insurer's or
employer's filing available to the public upon request. The
administrative director may not publicly disclose any information
submitted pursuant to this section that is determined by the
administrative director to be confidential pursuant to state or
federal law.
(c) For the purposes of this article, "economic profiling" shall
mean any evaluation of a particular physician, provider, medical
group, or individual practice association based in whole or in part
on the economic costs or utilization of services associated with
medical care provided or authorized by the physician, provider,
medical group, or individual practice association.

4616.2. (a) An insurer or employer that arranges for care for
injured employees through a medical provider network shall file a
written continuity of care policy with the administrative director.
(b) If approved by the administrative director, the provisions of
the written continuity of care policy shall replace all prior
continuity of care policies. The insurer or employer shall file a
revision of the continuity of care policy with the administrative
director if it makes a material change to the policy.
(c) The insurer or employer shall provide to all employees
entering the workers' compensation system notice of its written
continuity of care policy and information regarding the process for
an employee to request a review under the policy and shall provide,
upon request, a copy of the written policy to an employee.
(d) (1) An insurer or employer that offers a medical provider
network shall, at the request of an injured employee, provide the
completion of treatment as set forth in this section by a terminated
provider.
(2) The completion of treatment shall be provided by a terminated
provider to an injured employee who, at the time of the contract's
termination, was receiving services from that provider for one of the
conditions described in paragraph (3).
(3) The insurer or employer shall provide for the completion of
treatment for the following conditions subject to coverage through
the workers' compensation system:
(A) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of treatment shall be
provided for the duration of the acute condition.
(B) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of treatment shall be provided for a period
of time necessary to complete a course of treatment and to arrange
for a safe transfer to another provider, as determined by the insurer
or employer in consultation with the injured employee and the
terminated provider and consistent with good professional practice.
Completion of treatment under this paragraph shall not exceed 12
months from the contract termination date.
(C) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of treatment shall be provided
for the duration of a terminal illness.
(D) Performance of a surgery or other procedure that is authorized
by the insurer or employer as part of a documented course of
treatment and has been recommended and documented by the provider to
occur within 180 days of the contract's termination date.
(4) (A) The insurer or employer may require the terminated
provider whose services are continued beyond the contract termination
date pursuant to this section to agree in writing to be subject to
the same contractual terms and conditions that were imposed upon the
provider prior to termination. If the terminated provider does not
agree to comply or does not comply with these contractual terms and
conditions, the insurer or employer is not required to continue the
provider's services beyond the contract termination date.
(B) Unless otherwise agreed by the terminated provider and the
insurer or employer, the services rendered pursuant to this section
shall be compensated at rates and methods of payment similar to those
used by the insurer or employer for currently contracting providers
providing similar services who are practicing in the same or a
similar geographic area as the terminated provider. The insurer or
provider is not required to continue the services of a terminated
provider if the provider does not accept the payment rates provided
for in this paragraph.
(5) An insurer or employer shall ensure that the requirements of
this section are met.
(6) This section shall not require an insurer or employer to
provide for completion of treatment by a provider whose contract with
the insurer or employer has been terminated or not renewed for
reasons relating to a medical disciplinary cause or reason, as
defined in paragraph (6) of subdivision (a) of Section 805 of the
Business and Profession Code, or fraud or other criminal activity.
(7) Nothing in this section shall preclude an insurer or employer
from providing continuity of care beyond the requirements of this
section.
(e) The insurer or employer may require the terminated provider
whose services are continued beyond the contract termination date
pursuant to this section to agree in writing to be subject to the
same contractual terms and conditions that were imposed upon the
provider prior to termination. If the terminated provider does not
agree to comply or does not comply with these contractual terms and
conditions, the insurer or employer is not required to continue the
provider's services beyond the contract termination date.

4616.3. (a) When the injured employee notifies the employer of the
injury or files a claim for workers' compensation with the employer,
the employer shall arrange an initial medical evaluation and begin
treatment as required by Section 4600.
(b) The employer shall notify the employee of his or her right to
be treated by a physician of his or her choice after the first visit
from the medical provider network established pursuant to this
article, and the method by which the list of participating providers
may be accessed by the employee.
(c) If an injured employee disputes either the diagnosis or the
treatment prescribed by the treating physician, the employee may seek
the opinion of another physician in the medical provider network. If
the injured employee disputes the diagnosis or treatment prescribed
by the second physician, the employee may seek the opinion of a third
physician in the medical provider network.
(d) (1) Selection by the injured employee of a treating physician
and any subsequent physicians shall be based on the physician's
specialty or recognized expertise in treating the particular injury
or condition in question.
(2) Treatment by a specialist who is not a member of the medical
provider network may be permitted on a case-by-case basis if the
medical provider network does not contain a physician who can provide
the approved treatment and the treatment is approved by the employer
or the insurer.

4616.4. (a) (1) The administrative director shall contract with
individual physicians, as described in paragraph (2), or an
independent medical review organization to perform independent
medical reviews pursuant to this section.
(2) Only physicians licensed pursuant to Chapter 5 (commencing
with Section 2000) of the Business and Professions Code may be
independent medical reviewers.
(3) The administrative director shall ensure that the independent
medical reviewers or those within the review organization shall do
all of the following:
(A) Be appropriately credentialed and privileged.
(B) Ensure that the reviews provided by the medical professionals
are timely, clear, and credible, and that reviews are monitored for
quality on an ongoing basis.
(C) Ensure that the method of selecting medical professionals for
individual cases achieves a fair and impartial panel of medical
professionals who are qualified to render recommendations regarding
the clinical conditions consistent with the medical utilization
schedule established pursuant to Section 5307.27, or the American
College of Occupational and Environmental Medicine's Occupational
Medicine Practice Guidelines.
(D) Ensure that confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
(E) Ensure the independence of the medical professionals retained
to perform the reviews through conflict-of-interest policies and
prohibitions, and ensure adequate screening for conflicts of
interest.
(4) Medical professionals selected by the administrative director
or the independent medical review organizations to review medical
treatment decisions shall be physicians, as specified in paragraph
(2) of subdivision (a), who meet the following minimum requirements:
(A) The medical professional shall be a clinician knowledgeable in
the treatment of the employee's medical condition, knowledgeable
about the proposed treatment, and familiar with guidelines and
protocols in the area of treatment under review.
(B) Notwithstanding any other provision of law, the medical
professional shall hold a nonrestricted license in any state of the
United States, and for physicians, a current certification by a
recognized American medical specialty board in the area or areas
appropriate to the condition or treatment under review.
(C) The medical professional shall have no history of disciplinary
action or sanctions, including, but not limited to, loss of staff
privileges or participation restrictions taken or pending by any
hospital, government, or regulatory body.
(b) If, after the third physician's opinion, the treatment or
diagnostic service remains disputed, the injured employee may request
independent medical review regarding the disputed treatment or
diagnostic service still in dispute after the third physician's
opinion in accordance with Section 4616.3. The standard to be
utilized for independent medical review is identical to that
contained in the medical treatment utilization schedule established
in Section 5307.27, or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
as appropriate.
(c) Applications for independent medical review shall be submitted
to the administrative director on a one-page form provided by the
administrative director entitled "Independent Medical Review
Application." The form shall contain a signed release from the
injured employee, or a person authorized pursuant to law to act on
behalf of the injured employee, authorizing the release of medical
and treatment information. The injured employee may provide any
relevant material or documentation with the application. The
administrative director or the independent medical review
organization shall assign the independent medical reviewer.
(d) Following receipt of the application for independent medical
review, the employer or insurer shall provide the independent medical
reviewer, assigned pursuant to subdivision (c), with all information
that was considered in relation to the disputed treatment or
diagnostic service, including both of the following:
(1) A copy of all correspondence from, and received by, any
treating physician who provided a treatment or diagnostic service to
the injured employee in connection with the injury.
(2) A complete and legible copy of all medical records and other
information used by the physicians in making a decision regarding the
disputed treatment or diagnostic service.
(e) Upon receipt of information and documents related to the
application for independent medical review, the independent medical
reviewer shall conduct a physical examination of the injured employee
at the employee's discretion. The reviewer may order any diagnostic
tests necessary to make his or her determination regarding medical
treatment. Utilizing the medical treatment utilization schedule
established pursuant to Section 5307.27, or the American College of
Occupational and Environmental Medicine's Occupational Medicine
Practice Guidelines, as appropriate, and taking into account any
reports and information provided, the reviewer shall determine
whether the disputed health care service was consistent with Section
5307.27 or the American College of Occupational and Environmental
Medicine's Occupational Medicine Practice Guidelines based on the
specific medical needs of the injured employee.
(f) The independent medical reviewer shall issue a report to the
administrative director, in writing, and in layperson's terms to the
maximum extent practicable, containing his or her analysis and
determination whether the disputed health care service was consistent
with the medical treatment utilization schedule established pursuant
to Section 5307.27, or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
as appropriate, within 30 days of the examination of the injured
employee, or within less time as prescribed by the administrative
director. If the disputed health care service has not been provided
and the independent medical reviewer certifies in writing that an
imminent and serious threat to the health of the injured employee may
exist, including, but not limited to, serious pain, the potential
loss of life, limb, or major bodily function, or the immediate and
serious deterioration of the injured employee, the report shall be
expedited and rendered within three days of the examination by the
independent medical reviewer. Subject to the approval of the
administrative director, the deadlines for analyses and
determinations involving both regular and expedited reviews may be
extended by the administrative director for up to three days in
extraordinary circumstances or for good cause.
(g) The independent medical reviewer's analysis shall cite the
injured employee's medical condition, the relevant documents in the
record, and the relevant findings associated with the documents or
any other information submitted to the reviewer in order to support
the determination.
(h) The administrative director shall immediately adopt the
determination of the independent medical reviewer, and shall promptly
issue a written decision to the parties.
(i) If the determination of the independent medical reviewer finds
that the disputed treatment or diagnostic service is consistent with
Section 5307.27 or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
the injured employee may seek the disputed treatment or diagnostic
service from a physician of his or her choice from within or outside
the medical provider network. Treatment outside the medical provider
network shall be provided consistent with Section 5307.27 or the
American College of Occupational and Environmental Medicine's
Occupational Practice Guidelines. The employer shall be liable for
the cost of any approved medical treatment in accordance with Section
5307.1 or 5307.11.

4616.5. For purposes of this article, "employer" means a
self-insured employer, joint powers authority, or the state.

4616.6. No additional examinations shall be ordered by the appeals
board and no other reports shall be admissable to resolve any
controversy arising out of this article.

4616.7. (a) A health care organization certified pursuant to
Section 4600.5 shall be deemed approved pursuant to this article if
it meets the percentage required for physicians primarily engaged in
nonoccupational medicine specified in subdivision (a) of Section 4616
and all the other requirements of this article are met, as
determined by the administrative director.
(b) A health care service plan, licensed pursuant to Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code, shall be deemed approved for purposes of this article if it
has a reasonable number of physicians with competency in occupational
medicine, as determined by the administrative director.
(c) A group disability insurance policy, as defined in subdivision
(b) of Section 106 of the Insurance Code, that covers hospital,
surgical, and medical care expenses shall be deemed approved for
purposes of this article if it has a reasonable number of physicians
with competency in occupational medicine, as determined by the
administrative director. For the purposes of this section, a group
disability insurance policy shall not include Medicare supplement,
vision-only, dental-only, and Champus-supplement insurance. For
purposes of this section, a group disability insurance policy shall
not include hospital indemnity, accident-only, and specified disease
insurance that pays benefits on a fixed benefit, cash-payment-only
basis.
(d) Any Taft-Hartley health and welfare fund shall be deemed
approved for purposes of this article if it has a reasonable number
of physicians with competency in occupational medicine, as determined
by the administrative director.