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AB-1465 Workers’ compensation: medical provider networks study.(2021-2022)

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Date Published: 04/26/2021 10:00 AM
AB1465:v97#DOCUMENT

Amended  IN  Assembly  April 26, 2021
Amended  IN  Assembly  April 15, 2021

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Assembly Bill
No. 1465


Introduced by Assembly Members Reyes and Lorena Gonzalez

February 19, 2021


An act to add and repeal Section 4617 to 77.9 of the Labor Code, relating to workers’ compensation.


LEGISLATIVE COUNSEL'S DIGEST


AB 1465, as amended, Reyes. Workers’ compensation: medical treatment. provider networks study.
Existing law establishes a workers’ compensation system, administered by the Administrative Director of the Division of Workers’ Compensation, to compensate an employee, as defined, for injuries sustained in the course of employment. Existing law requires an employer to provide medical treatment that is reasonably required to cure or relieve an employee from the effects of the injury. Existing law allows employers to create networks of medical treatment providers to send employees to for treatment. Existing law sets out criteria for these networks and exceptions for when an employee may be treated outside the network. Existing law establishes the Commission on Health and Safety and Workers’ Compensation to conduct a continuing examination of the workers’ compensation system.

This bill would require the administrative director to establish a statewide medical provider network, called the California Medical Provider Network (CAMPN). The bill would establish that an employee may choose to treat within their employer’s network or the CAMPN. The bill would require that the providers in the CAMPN be sufficient to enable treatment for a variety of injuries in all parts of the state. The bill would specify criteria physicians must meet to be included in the CAMPN and would require inclusion for those physicians that meet the criteria. The bill would require the administrative director, no later than April 30, 2022, to establish rules and procedures for the CAMPN and create and adopt a continuity of care policy. The bill would require that the administrative director implement the CAMPN on or before June 30, 2022. The bill would authorize a treatment provider to leave the CAMPN at any time.

This bill would require the Commission on Health and Safety and Workers’ Compensation, on or before January 1, 2023, to submit a study to the Legislature, the committees of the Senate and Assembly with jurisdiction over workers’ compensation, and the Division of Workers’ Compensation on delays and access to care issues in medical provider networks. The bill would require the study to compare specified data for injury claims in which a worker was treated by a medical provider network to that data for injury claims in which a worker was treated by a provider who is not part of a medical provider network.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 Section 77.9 is added to the Labor Code, to read:

77.9.
 (a) On or before January 1, 2023, the Commission on Health and Safety and Workers’ Compensation shall submit a study to the Legislature, the committees of the Senate and Assembly with jurisdiction over workers’ compensation, and the Division of Workers’ Compensation on delays and access to care issues in medical provider networks. At a minimum, the study shall include all of the following:
(1) An examination of injury claims in which a worker was treated by a medical provider network compared to injury claims in which a worker was treated by a provider who is not part of a medical provider network to determine the length of time between injury and initial treatment in the two systems and the reason for potential delays before workers receive initial treatment.
(2) An examination of injury claims in which a worker was treated by a medical provider network compared to injury claims in which a worker was treated by a provider who is not part of a medical provider network to determine the frequency and causes of delays after a worker receives initial treatment.
(3) An examination of injury claims in which a worker was treated by a medical provider network compared to injury claims in which a worker was treated by a provider who is not part of a medical provider network to determine the distance, in miles, between the injured worker and the treating provider, including primary care physicians and specialty physicians.
(b) The report submitted pursuant to subdivision (a) shall be submitted in compliance with Section 9795 of the Government Code.
(c) This section shall remain in effect only until January 1, 2025, and as of that date is repealed.

SECTION 1.Section 4617 is added to the Labor Code, to read:
4617.

(a)The administrative director shall establish a statewide medical provider network to be called the California Medical Provider Network (CAMPN). The CAMPN shall consist of physicians, as described in Section 3209.3, throughout the state who are willing and able to provide medical treatment to injured employees.

(b)Notwithstanding any other provision of law, if the employer or insurer has established a medical provider network (MPN) pursuant to Section 4616, or a health care organization (HCO) pursuant to Section 4600.3, the injured employee may choose to treat with a physician in that MPN or HCO, or may choose to transfer treatment to a physician in the CAMPN. If the employer or insurer has not established an MPN, the employee may choose to treat with a physician of the employee’s choice, as provided in subdivision (c) of Section 4600, or to treat with a physician in the CAMPN. An employee who is treating with a physician in the CAMPN may, at any time, change to a different treating physician within the CAMPN. Nothing in this section shall be construed to limit the right of an employee to treat with their personal physician as described in subdivision (d) of Section 4600.

(c) The number of physicians in the CAMPN shall be sufficient to enable treatment for injuries or conditions to be provided in a timely manner and shall, to the extent feasible, include within the CAMPN physicians in all medical specialties. The CAMPN shall include an adequate number and type of physicians, as described in Section 3209.3, 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. 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 and areas in which there is a health care shortage.

(d) A physician who possesses the requisite license for practice of their medical specialty is eligible for inclusion in the CAMPN, if all of the following apply:

(1)The physician is in good standing with the Medical Board of California.

(2)The physician has not been suspended pursuant to Section 139.21.

(3)The physician does not meet any of the criteria specified in paragraph (1) of subdivision (a) of Section 139.21.

(4)The physician agrees to treat injured workers within the scope of their medical practice.

(5)The physician agrees to bill in accord with the official medical fee schedule established pursuant to Section 5307.1.

(6)The physician agrees to practice in accord with rules and regulations applicable to the workers’ compensation system, including preparation of required reports.

(e)A physician who meets the criteria in subdivision (d) shall be included in the CAMPN. In no event shall economic profiling, as defined in subdivision (c) of Section 4616.1, be a factor to be considered for inclusion in or expulsion from the CAMPN.

(f)All treatment within the CAMPN shall be provided in accordance with the medical treatment utilization schedule established pursuant to Section 5307.27, which remains presumptively correct.

(g)Treatment within the CAMPN shall be subject to utilization review, as described in Section 4610, and independent medical review, as described in Section 4610.5.

(h)Nothing contained herein shall be construed to limit or eliminate utilization review as described in Section 4610, independent medical review as described in Section 4610.5 or 4610.6, or the antifraud provisions contained in Sections 139.21 and 4906 of this code, and Section 14123 of the Welfare and Institutions Code.

(i)The initial list of CAMPN physicians shall be created by including any physician who meets the criteria in subdivision (d) and was listed as of January 1, 2021, on any MPN created pursuant to Section 4616. Within 60 days of the effective date of this section, each employer, insurer, or private entity, that has established an MPN pursuant to Section 4616, shall file with the administrative director a list of those physicians in the MPN as of January 1, 2021.

(j)The administrative director shall, on or before April 30, 2022, and after public hearings, establish rules and procedures governing the CAMPN. The administrative director shall include a continuity of care policy meeting the requirements of Section 4616.2. The CAMPN shall be implemented no later than June 30, 2022.

(k)A physician in the CAMPN may, at any time, leave the CAMPN pursuant to the rules and procedures created by the administrative director.