Instructions for Accessing the Provider Affirmation Portal Online. Affirming MPN Participation or Opting Out

Transcription

1 Instructions for Accessing the Provider Affirmation Portal Online Affirming MPN Participation or Opting Out Anthem Workers Compensation, LLC maintains a website portal where physicians and groups are able to observe the MPN or MPNs that access the Anthem Prudent Buyer PPO network and have selected the physician or group for participation. A physician or group, or an agent or representative authorized on behalf of the providers can complete the online form in the provider affirmation portal to affirm in or opt out of the MPN Applicant s MPN. In addition, if the provider does not wish to visit the portal, Anthem Workers Compensation LLC will use its MPN Services group to assist the provider in affirming MPN participation or opting out of our clients MPNs as needed. You must affirm your MPN participation no later than 12/31/2015 for any MPN that you have been selected for to maintain your MPN status per California Code of MPN Regulations Section (e)(5). It is also your responsibility to periodically check the Anthem Provider Affirmation Portal for newly added MPNs. Three simple steps to affirming MPN participation or opting out: 1) To access the Anthem Workers Compensation Provider Affirmation Portal for Medical Provider Networks, go online to the Anthem Blue Cross website anthem.com/ca > Providers > ProviderAccess and log in. Click on Availity on the right hand side. Alternatively, you can go directly to Availity.com and login there. If you do not have your Availity login information, use the Forgot User Name or Forgot User Password options on the page. Once in, click on Payer Resources at the top and look for the link to the Provider Affirmation Portal for Workers Compensation MPNs. 2) Access the Provider Affirmation Portal to view a list of the MPNs that access Anthem s workers compensation network of Participating Providers and subscribe to the portal for their affirmation process. If the MPN Applicant (insurance carrier, self-insured employer, Entities Providing Physician Network Services) has selected you to participate in their MPN, you will find their MPN(s) listed and you can affirm in by simply viewing the page and clicking submit at the bottom of the page. 3) If you do not wish to participate in a particular MPN, as a physician you have the right to opt out of any MPN that includes you as a participating provider pursuant to CCR Simply select the button in the column for opt out and click submit. If you have opted out of an MPN and wish to rejoin, you may Request Reinstatement in the portal which will go to the MPN for review and consideration per their exclusive right pursuant Labor Code 4616 (d). If you do not see an MPN listed, the MPN is either not an Anthem client, has not subscribed to this affirmation portal service, or has not selected you to participate in their MPN. Please contact the MPN directly to inquire or affirm MPN participation. For more information regarding the required Physician Acknowledgments and our Anthem Provider Affirmation Portal please see the enclosed Anthem Workers Compensation Manual and look for the section on Affirming MPN Participation or Opting Out.

2 Anthem Workers Compensation Manual Medical Provider Network (MPN)... 2 Advantages of Being in an MPN... 2 Maintaining Your Anthem Workers Compensation Network and/or MPN Status... 2 MPN Regulations, Provider Selection, Referrals and Authorized Treatment... 3 Online Provider Directory... 4 Physician Referrals Within the Anthem Workers Compensation Network or Other Payor MPN... 5 Physician Referrals Regulatory Compliance... 5 Medical Treatment Utilization Schedule (MTUS)... 5 Guide for the Treating Physician... 5 California Code of Regulations 9785 Reporting Duties of the Primary Treating Physician... 6 Other Responsibilities of the Primary Treating Physician... 6 Rules for Calculating Permanent Disability... 7 Network Leasing... 7 PPO and MPN Network Participation... 7 Affirming MPN Participation or Opting Out of an Individual MPN... 7 Opting Out of ALL Anthem Workers Compensation... 8 Notification Requirements... 8 Network Pricing Questions... 8 Practice Focus: Workers Compensation Services Only... 8 Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 1

3 Medical Provider Network The Workers Compensation Reform Legislation, SB 899, was enacted to address many of the primary cost drivers and related issues regarding the State of California s Workers Compensation system. This bill allows MPN Applicants (self-insured employers, insurance carriers, and now Entities Providing Physician Network Services with the adoption of the SB 863 regulations effective 8/27/14) to submit a list of participating medical Providers to be included in their Medical Provider Network (MPN) for use by injured workers. The MPN Applicant has the exclusive right to determine the participating Providers in its MPN. Advantages of Being in an MPN A MPN is similar to a health plan in which an injured worker must seek treatment from a contracted Provider within the Prudent Buyer Network. By participating in an MPN, injured workers will be channeled for treatment, which includes referrals to our other contracted participating Providers, hospitals, ambulatory surgery centers, laboratories, ancillary networks and Behavioral Health networks within Anthem Workers Compensation. Insurance carriers, Self-Insured Employers and Entities Providing Physician Network Services who have selected you to participate in their MPN will have control of medical direction and channeling of an injured worker s care to MPN physicians for the entire life of the claim. The Anthem Blue Cross EAP Network will not receive referrals for injured workers who are also covered under an Anthem commercial health plan. In the event this occurs, the Anthem Blue Cross EAP Practitioner shall refer the injured worker back to the employer or claims adjuster for their work-related injury or illness. Please contact the insurer or employer directly prior to providing non-emergency medical treatment or services. If you wish to confirm your MPN participation or do not wish to participate in a specific MPN see the instructions beginning on page 7 in section Affirming MPN Participation or Opting Out of Treating Work-related Injuries. Maintaining Your Anthem Workers Compensation Network and/or MPN Status To ensure you and/or your group are correctly listed in the directory and available to be selected for an MPN, please follow the steps below. If these steps are not followed, you could be removed from the network and/or Provider directory, which may affect your Anthem Workers Compensation Network and/or MPN status: 1. It is important to ensure you maintain accurate directory data (addresses, phone numbers and roster of participating physicians that treat Workers Compensation (if applicable) as only Providers listed in the directory can be part of an MPN. Further, SB 863 MPN Regulations state any Medical Group that wishes to participate in the MPN shall maintain and update the active roster of physicians associated with the Medical Group and report any additions, terminations or demographic changes. You can report changes in roster information directly to WCRosters@anthemwc.com. If you leave a group and do not have a contract for your new TIN (Tax ID Number), you may experience a gap in your participation. 2. If you leave a group that has delegated credentialing and are part of another participating group, if that group is not approved by Anthem to have delegated credentialing, you must initiate CAQH/Credentialing with Anthem within 60 days of leaving the delegated group to continue your participation. To do so please CAcontractsupport@anthem.com or call MPN Services at Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 2

4 and they will connect you. You must receive Anthem credentialing/recredentialing approval to maintain network and MPN participation. 3. If you add or change a specialty, you must contact Anthem to have the Credentialing Department process your change before it can be updated on your Provider directory listing. 4. If you are unable to accept new patients, you must refer them within the MPN to a participating Provider (see section Physician Referrals within the Anthem Workers Compensation Network or Other Payor MPN ). Help in doing so can be obtained by contacting the MPN Services department at If you do not treat Workers Compensation patients, please contact our MPN Services department at If you are removed from the workers compensation PPO you will be removed from the workers compensation directory located at This action will also result in your removal from our clients Medical Provider Network (MPN) listings. If you were previously terminated from the PPO network for any reason (contract non-compliance, did not complete credentialing, etc) and wish to renew your contract you may request reinstatement to the Anthem Workers Compensation Network with the approval from the Workers Compensation Medical Director. However, this does not automatically reinstate you into the insurer s, employer s, or Entities Providing Physician Network Services MPN. You should contact the client or MPN Services to confirm if you will be reinstated in each MPN you previously participated. MPN Regulations, Provider Selection, Referrals and Authorized Treatment The DWC has established MPN regulations for injured workers to access care and guidelines to improve the quality of medical care for occupational injuries. MPNs have the exclusive right per California Labor Code 4616 (d) to determine the members of their Medical Provider Network. Participation in the Anthem Workers Compensation Network makes you available to be selected by an MPN. If you have been selected as an MPN Provider you must adhere to the guidelines below in order to assist the MPN in providing for the injured worker s medical needs and maintaining medical control for the life of the claim: Refer within the MPN. For employers and carriers accessing the Anthem Workers Compensation PPO Network for their MPN, this means referrals must be made to Providers participating in the Anthem Workers Compensation PPO Network that are included in the specific MPN for an employer, insurance carrier, Entity Providing Physician Network Services or Other Payor. Contact our MPN Services department at for assistance or refer to the Other Payor listing, which may include MPN Program Contact and/or the online Provider search websites for clients that utilize the Anthem network for their MPN. Services obtained outside of the MPN may not be paid. If you have not been selected to participate in the specific MPN covering the injured worker, your services may be considered outside the MPN and will not be reimbursable unless specifically authorized as out of MPN treatment. Contact the claims adjuster for authorization for any medical care outside of the MPN. The injured worker may select a physician of his or her choice from within the MPN, at any point in time after the initial medical evaluation with an MPN physician. Selection by the injured worker 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. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 3

5 If a chiropractor is selected as a treating physician, the chiropractor may act as a treating physician only until the 24-visit cap is met unless otherwise authorized by the employer or insurer, after which the injured worker must select another treating physician in the MPN who is not a chiropractor, and if the injured worker fails to do so, then the insurer or employer may assign another treating physician who is not a chiropractor pursuant to C.C.R If the injured worker disputes the diagnosis or treatment plan of the MPN Provider, there is a second- and third-opinion process established by the Administrative Director of the DWC included as part of the MPN policies and procedures. Maintain medical records, records of accounts and payments, reports, and other documents that were necessary for the delivery of the medical services. These must be maintained for at least five years from the date of delivery of the medical service, and the obligation to maintain such records does not end on termination of the Agreement with the Prudent Buyer Network. All such records, including records pertaining to the cost to the health care practitioner for delivery of the medical care and the payments received by the health care practitioner for such care, will be made available to the MPN, on request, during regular business hours. Requests for Authorization (RFA) should be submitted to the Claims Administrator or Utilization Review Organization using the DWC Form RFA, following the treatment guidelines found in the Medical Treatment Utilization Schedule (MTUS). The DWC Form RFA must include as an attachment documentation substantiating the need for the requested treatment. Services provided without proper authorization pursuant to CA Labor Code 4610 may not be reimbursable. While a claim is under investigation the claims administrator will ensure payment for authorized medical services rendered, pursuant to CA Labor Code 5402 (c), until such time as a denial of the claim is made by the claims administrator. Submit medical bills within 60 days following delivery of health care services to the appropriate Workers Compensation administrator. CA Labor Code 3751 (b) prohibits any surcharges or other billings for Workers Compensation health care services or balance billing the injured worker. Demonstrate participation in educational activities for occupational medicine and Workers Compensation, including, but not limited to: 1. Regulatory requirements for primary treating physicians 2. Workplace health and safety issues 3. Vocational rehabilitation Online Provider Directory For Anthem Workers Compensation PPO Services, the workers compensation online Provider directory is available by visiting and selecting California. Assistance is also available by calling This online Provider directory will identify Providers who treat workrelated illness or injuries. To refer to other providers within an MPN, please visit the client MPN directory. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 4

6 Physician Referrals Within the Anthem Workers Compensation Network or Other Payor MPN As required by your Anthem Agreement, referrals to specialist or our other contracted participating Providers, hospitals, ambulatory surgery centers, ancillary networks and Behavioral Health networks must be within the Anthem Workers Compensation Network or for clients that have an MPN, within the client s MPN. To ensure that you utilize the correct online directory please refer to the list of Other Payors for Workers Compensation Network Leasing, which is available on the Anthem secure portal for ProviderAccess site. Click on link for Network Leasing Arrangements to download the list and search for Payors that have a specific directory web address. For instructions on how to log on to ProviderAccess, see below: You must have a ProviderAccess account and PIN for secure access. If you do not have an account, you may register at ProviderAccess. Only authorized users can access the website. You, the Provider, are given rights to assign user levels of access and identifications to your own staff. This is handled by the individual on your staff who has administrator rights for management of the ProviderAccess account. ProviderAccess is available 24 hours a day, 7 days a week, except during scheduled maintenance and national holidays. ProviderAccess offers printer-friendly format on all information screens. ProviderAccess Login and Technical Support: o For password related questions, system outages, error messages, and/or technical difficulties, please contact us at , Monday through Friday, 5 a.m. to 5 p.m. PST. Physician Referrals Regulatory Compliance CA Labor Code states it is unlawful for a physician to refer a person for medical services as defined in sections and , whether for treatment or medical-legal purposes, if the physician or his or her immediate family has a financial interest with the person or in the entity that receives the referral. Medical Treatment Utilization Schedule (MTUS) For all dates of injury, the presumption of correctness regarding appropriate medical treatment is the California Medical Treatment Utilization Schedule (MTUS). Information about these guidelines can be obtained by accessing Guide for the Treating Physician The DWC has established MPN regulations for injured workers to access care and guidelines to improve the quality of medical care for occupational injuries. A Guide for the Treating Physician in the Workers Compensation System has been written and is posted on our website in the California Resources and Forms section for Providers. Go to and select California from the Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 5

7 Select a Service Area drop down menu under Forms and Resources. This guide outlines some of the very important duties and requirements of the treating physician as outlined in the California Labor Code. We would encourage you to read this guide and become familiar with the California state mandated requirements. Below we have outlined some of the reporting requirements. California Code of Regulations 9785 Reporting Duties of the Primary Treating Physician Click the link, to view the regulation. Within five (5) calendar days of initial visit, a Doctor s First Report of Injury or Illness (form 5021) must be completed and sent to the Claims Administrator. This must be submitted by each new primary treating physician. The form must be completed including the information regarding frequency and duration of planned treatments, consultations, referrals, surgery or hospitalization, and the type, frequency and duration of planned physical medicine treatment on the reverse side of the form. These forms are available at Additional reports (PR2) shall be submitted within twenty (20) days if the injured workers condition undergoes a previously unexpected significant change, there is any significant change to the treatment plan reported previously, the injured worker is felt to be capable of returning to modified or regular work, the injured worker s condition requires him/her to leave work or requires changes in the work restrictions, the injured worker is released from medical care, or the injured worker is felt to be unable eventually to return to his/her usual occupation or the occupation in which the injured worker was engaged in at the time of the injury. When continuing medical treatment is provided, the PR2 shall be submitted no later than forty-five (45) days from the previous report but no later than twenty (20) days of the examination. These forms are available at If a narrative report is submitted, it should be clearly titled Primary Treating Physician s Progress Report and should contain the same information as the PR2. A narrative report must have the mandated declaration below the signature of: I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code When the physician determines that the injured worker s condition is permanent and stationary [maximum medical improvement (MMI)], the physician shall report this within twenty (20) days from the date of examination any findings concerning the extent of permanent impairment and limitations and any need for continuing and/or future care on the Primacy Treating Physician s Permanent and Stationary Report, which is Form PR3 or PR4. These are available at Permanent disability evaluation should be performed in accordance with the AMA Guides to the Evaluation on Permanent Impairment, which at the time of this document is the 5 th Edition. The physician is also able to refer the injured worker to another MPN physician for this report and if this is necessary, it should be discussed with the Claims Examiner. Other Responsibilities of the Primary Treating Physician Availability For non-emergency services, the primary treating physician must see the injured worker within three (3) business days of the request. For specialty services, the specialist must see the injured worker within twenty (20) business days of the request. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 6

8 Causation When requested, the treating physician must address causation issues. Causation is the medical likelihood that the diagnosis is causally related to the mechanism of injury alleged to have occurred as related to employment. Medication issues Under the California Labor Code, the physician is to prescribe generic drugs unless clearly documented for reason that brand drugs are required and comply with a Pharmacy Benefit Program. The physician is obligated to use the Pharmacy Benefit Program when made available to the injured worker and may not dispense medication from the office. The provision and prescription of compounded medications is not allowed as a part of the any Anthem MPN unless there is clear and documented reason, approved through the Insurer or Self Insured Employer UR Process, for such medication. The physician is to prescribe medication in accordance with MTUS Chronic Pain Treatment Guidelines, the proposed regulations are available at: Regulations/MTUS_ChronicPainMedicalTreatmentGuidelines.pdf Rules for Calculating Permanent Disability The calculation of permanent disability is to be conducted in accordance with the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, presently utilizing the 5 th Edition. Information about this guide can be obtained by accessing If you feel you are unable to write the permanent and stationary report, contact the claims examiner to refer the patient to another physician to prepare a report utilizing these guides. Network Leasing Anthem Workers Compensation Payors, Other Payors (PPO and MPN) We are providing a listing of our Other Payors (Workers Compensation Insurance Carriers, Self Insured s including Self-Insurer s Security Fund, a group of self-insured employers pursuant to CA Labor Code section 3700(b) and as defined by Title 8, C.C.R. 5402, a joint powers authority (JPA), the State and Third Party Administrators or Entities Providing Physician Network Services) who are leasing the network access to our Anthem Workers Compensation Network, which is comprised of our Prudent Buyer Network and may be used both as PPO and MPN. To access a list of participating payors, go online to the Anthem Blue Cross website anthem.com/ca > Providers > ProviderAccess and log in to obtain access. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 7

9 Affirming MPN Participation or Opting Out of an Individual MPN According to the California Department of Workers Compensation, as authorized by California Code of MPN Regulations (CCR) Title 8 Chapter 4.5 Subchapter 1 Article 3.5 Section , an MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN. An electronic acknowledgment using generally accepted means of authentication to confirm the identity of the person making the acknowledgment is allowed. Anthem Workers Compensation, LLC maintains a website portal where physicians and groups are able to observe the MPN or MPNs that access the Anthem Prudent Buyer PPO network and have selected the physician or group for participation. A physician or group, or an agent or representative authorized on behalf of the providers can complete the online form in the provider affirmation portal to affirm in or opt out of the MPN Applicant s MPN. In addition, if the provider does not wish to visit the portal, Anthem Workers Compensation LLC will use its MPN Services group to assist the provider in affirming MPN participation or opting out of our clients MPNs as needed in compliance with CCR (e)(5)(B). Logging on to the Provider Affirmation Portal for Workers Compensation 1) Access the Anthem provider portal known as Availity. If the medical provider is not yet signed up for this portal, instructions are provided below. To register for Availity: a) Go to availity.com. Click Get Started. b) Complete the online registration wizard by clicking Start Registration. c) You will receive an from Availity with a temporary password and next steps. Applications are approved and temporary passwords sent within three to five business days. d) If you need further assistance, please contact Availity Client Services at: ) Once you have logged into Availity, click on Payer Resources at the top of the page. Anthem Workers Compensation will appear with a link directly below for the MPN Provider Affirmation Portal. Click this link and boxes will appear for you to select your Organization and confirm the Provider s License Number. Agree to the terms in the disclaimer to be redirected to the Provider Affirmation Portal hosted by Anthem Workers Compensation. You will again have to confirm your license before entering. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 8

10 3) MPN Affirm In or Opt Out In the Provider Affirmation Portal you can view any MPNs you have been selected for and that have subscribed to the portal. Not all of Anthem s clients have subscribed for the service to be listed in this portal so if you do not see an MPN listed you will need to contact them directly to affirm participation or opt out of their MPN. By participating in the Anthem Workers Compensation PPO Network you also agree to participate in any MPN you have been selected for and pursuant to (e)(5)(B) you have the obligation to view the portal described herein which displays a list of MPNs and affirm in to maintain MPN participation or opt out of any individual MPN if you desire. a. Affirm In- Continue your participation in the MPNs you have been selected for simply by viewing the page showing the MPNs you are a member of and clicking submit at the bottom of the page. If you enter an address you will receive a confirmation of those affirmations. b. Opt Out- You are able to opt out of any MPN listed in the portal by checking the button for MPN Opt Out next to the MPN you do not wish to participate in. Once you select an option you must scroll to the bottom to finalize your changes by confirming your provider identification and agreeing to the terms and conditions. If you enter an address you will receive a confirmation of those opt outs. Each MPN shows three status options in the Portal: a) Active MPN: this option indicates whether or not you are currently participating. Active cannot be selected however, you are active either because an MPN has selected you to participate or you were granted reinstatement by the MPN. b) Opt Out: this is the option available for each MPN to allow you to opt out of participating in that MPN. If you opt out and later wish to participate you will be required to request reinstatement from the MPN Applicant. For clients that have more than one MPN listed, you will notice there is only one Opt Out button that can be selected. If you wish to opt out Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 9

11 of one of the MPNs for that client, the MPN has decided that you will be removed from all of their MPNs. c) Request Reinstatement: this option allows you to communicate with the MPN and request to be reinstated to participate in the MPN. You can only request reinstatement once you have formally opted out of an MPN, and only the MPN can approve a reinstatement request. 4) Opt Out of Anthem Workers Compensation PPO Network In the middle of the page there is also an option to opt out of Anthem Workers Compensation Network entirely. Opting out of the Anthem Workers Compensation Network will terminate your participation in the Anthem Workers Compensation PPO Network and will remove you from all Anthem-client MPNs that you are participating in. This may trigger a Continuity of Care situation as described in section CCR Further authorization by the MPN or Other Payors may not be provided and the injured workers you are treating at the time of your opt out may be transferred to other MPN providers for continued treatment. If at some point in the future you elect to treat Injured Workers, you may request reinstatement to the Anthem Workers Compensation Network with the approval from the Workers Compensation Medical Director. However, this will not automatically reinstate you into our clients MPNs. To confirm your MPN status after reinstatement in the Anthem Workers Compensation Network, please contact the insurance carrier, selfinsured employer, or entity providing physician network services directly. If you do not treat workers compensation patients and wish to opt out of all workers compensation, check the box to Opt Out of ALL Workers Compensation, then scroll to the bottom of the page to confirm your name and address, check the I agree disclaimer and submit your changes. By selecting this option to opt out of all workers compensation you agree to allow Anthem Workers Compensation Services to initiate the process to remove you from the workers compensation directory located at As previously stated, this action will also result in your removal from our clients Medical Provider Network (MPN) listings. Opting out of all workers compensation will only reflect your desire to not participate in the Anthem Workers Compensation network. In the event you do treat an Anthem Workers Compensation Injured Worker, you will be bound by the terms and conditions of the Anthem Prudent Buyer agreement and will be reimbursed accordingly. Dates Legend and History Tracking Included on the page is a Date Legend with letters to track prior action taken in the portal. These letters with associated dates will populate in the date column on the far right hand side for each MPN listed. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 10

12 1) V= Listing Viewed. This indicates you logged in and viewed the listing of MPNs. 2) O= Opt Out, Not in MPN. After you have formally opted out of an MPN and submitted those changes, an O will display. 3) R= Requested Reinstatement. If you previously opted out of an MPN and have requested reinstatement, an R will display. 4) P= Participation Reactivated. If you request reinstatement for an MPN after opting out, and are approved to rejoin the MPN by the MPN Applicant, a P will display. 5) D= Denied. If you request reinstatement for an MPN after opting out, and are denied reinstatement by the MPN Applicant, a D will display. Medical Provider s Ongoing Responsibility to Affirm MPN Participation Please be advised as an Anthem Workers Compensation Network participating medical provider and pursuant to (e)(5)(B) or (b)(2) for groups, you are required to periodically return to the Provider Affirmation Portal to affirm participation in MPNs and ensure the roster of treating physicians is up to date. As clients implement new MPNs they may be added to the portal and will require you to affirm participation, or opt out if you desire. The California Code of MPN Regulations also requires providers to affirm participation at certain milestones bulleted below: If a physician or medical group enters into a new contract or renews a contract to participate in the MPN, the acknowledgment/affirmation of MPN participation shall be obtained at the time of entering into or renewing the contract. If a physician joins a medical group that already has a contract to participate in an MPN or MPNs, the acknowledgment/affirmation shall be obtained at the time of the physician s joining the medical group. Notification Requirements Notification must be in writing, signed and dated by the practitioner and sent to: Anthem Workers Compensation MPN Services P.O Box Anaheim, CA Fax: Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 11

13 Network Pricing Questions Workers Compensation For questions regarding payment per your contract rate, please contact AWC at Note: If you have a question regarding how the California Official Medical Fee Schedule was applied, please contact the customer service number on the EOR. Practice Focus: Workers Compensation Services Only Participating Providers who only treat Workers Compensation services injuries or illness may request an Anthem Blue Cross Occupational Medicine Network Participating Agreement or Mental Health Practitioner Agreement depending upon your specialty (medical vs. behavioral health). Participating practitioners may send written notice to Anthem Workers Compensation MPN Services. See the Notification Requirements information. Anthem Blue Cross Professional Manual October 2015 Workers Compensation: Page 12

14 October 20, 2015 Re: Anthem Premier MPN (MPN ID# 2397) and Anthem Premier Plus MPN (MPN ID #2415) Economic Profiling Policies for review Dear MPN Provider, Please see the attached Anthem Premier MPN and Anthem Premier Plus MPN Economic Profiling Policies for your records. As an MPN Applicant Anthem Workers Compensation, LLC is required to provide you with a copy of these policies as a participating Medical Provider Network (MPN) provider. These policies apply to the Anthem Premier MPN and Anthem Premier Plus MPN and are not related in any way to our Preferred Provider Organization (PPO) or any other medical provider networks that may access or lease the Anthem network of providers for workers compensation. If you have any questions regarding this policy please call (844) , PremierMPN@anthemwc.com, or by fax at (855) Sincerely, Reid Nelson MPN Product Management Director Anthem Workers Compensation, LLC Anthem Premier MPN Economic Profiling Policy 1) Overall description of the profiling methodology, data used to create the profile and risk adjustment According to the Department of Workers Compensation, Economic profiling means 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. Anthem Workers Compensation LLC possesses a comprehensive secure database of medical bills. Anthem WC can select a period of time for analysis for retrospective evaluation. This data describes both individual and physician group billing histories linked to workers compensation claims, with associated CPT Codes (Procedures), and ICD-9 Codes (Diagnoses) detail. As such, there is a clear description of physician practice habits associated with specific diagnoses for the care of injured or ill workers. The medical provider being examined with this process may be subdivided as to provider specialty type, nature of injuries treated, referral patterns, type of treatment ordered and frequency/duration, and other factors. Methodology: (Version 1, 9/16/15) 1

15 The database is examined with various rubrics, depending upon the specialty to be evaluated, though a strict description of the analytic methodology is considered proprietary. Such an algorithm may include information regarding use of diagnostic studies (e.g., laboratory, CT, MRI, and neurodiagnostics), surgery frequency by diagnosis (es), treatment duration, specialist referrals, variation from the State mean average on surgery and non-surgery statistics, referrals in and out of network, prescription of medications, dispensing of medications, use of compounded medications, etc. Indemnity and PBM data may be added to further enrich the analysis. Indemnity data is used to compare medical providers to their peers of similar (practice) in a geographic service area. Risk Adjustment is addressed by various correction factors. Most important among these is the Severity Rating correction. This places the ICD-9 Diagnoses into different categories of severity and rates the provider variables as impacted by severity. The intent is to allow some correction for those providers who may treat more severe or complex issues. 2) Description of how economic profiling is used in Utilization Review Anthem Workers Compensation, LLC ( Anthem ) is not a Utilization Review Organization, Utilization Review Agent, nor involved in any decisions related to a provider s request for authorization (RFA) of treatment. 3) A description of how economic profiling is used in peer review The Practice Habit Profiling used by Anthem Workers Compensation LLC is not utilized in peer review by Anthem. The Peer Review process for UR is a separate function and is presently not performed by Anthem. However, peer review information and profiling may be utilized in Quality Assurance as well as define the inclusion or exclusion of providers from the MPN as described below. 4) A Description of any incentives and penalties used in the program and in provider retention and termination decisions Anthem does not presently have any incentives or penalties as a part of practice profiling. However, intervention may take place if there were egregious indications of medical practice counter to the intent and execution of a quality assurance program. Such intervention would be with the intent of improving patient care, first using provider education to accomplish this goal. If quality of care cannot be changed and improved to an acceptable level for Anthem, the provider may not be retained as an MPN provider, regardless of need for such services, desire of the provider to remain in the MPN, or other factors. Providers with good practice habits are encouraged to be a part of the MPN. Due to the continuous nature of practice monitoring and newly contracted providers submitting bills, providers outside of the MPN may be considered for the MPN. Anthem Workers Compensation, LLC retains the exclusive right per MPN regulations to select or deselect physicians for its MPN per CCR Title 8, Section (c)(4) and (c)(5). 2 (Version 1, 9/16/15)

16 Anthem Premier Plus MPN Economic Profiling Policy 1) Overall description of the profiling methodology, data used to create the profile and risk adjustment According to the Department of Workers Compensation, Economic profiling means 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. Anthem Workers Compensation LLC possesses a comprehensive secure database of medical bills. Anthem WC can select a period of time for analysis for retrospective evaluation. This data describes both individual and physician group billing histories linked to workers compensation claims, with associated CPT Codes (Procedures), and ICD-9 Codes (Diagnoses) detail. As such, there is a clear description of physician practice habits associated with specific diagnoses for the care of injured or ill workers. The medical provider being examined with this process may be subdivided as to provider specialty type, nature of injuries treated, referral patterns, type of treatment ordered and frequency/duration, and other factors. Methodology: The database is examined with various rubrics, depending upon the specialty to be evaluated, though a strict description of the analytic methodology is considered proprietary. Such an algorithm may include information regarding use of diagnostic studies (e.g., laboratory, CT, MRI, and neurodiagnostics), surgery frequency by diagnosis (es), treatment duration, specialist referrals, variation from the State mean average on surgery and non-surgery statistics, referrals in and out of network, prescription of medications, dispensing of medications, use of compounded medications, etc. Indemnity and PBM data may be added to further enrich the analysis. Indemnity data is used to compare medical providers to their peers of similar (practice) in a geographic service area. Risk Adjustment is addressed by various correction factors. Most important among these is the Severity Rating correction. This places the ICD-9 Diagnoses into different categories of severity and rates the provider variables as impacted by severity. The intent is to allow some correction for those providers who may treat more severe or complex issues. Anthem s Economic Profiling Policy applies to Anthem s network of providers and does not apply to Kaiser on the Job medical providers. Kaiser does not perform economic profiling of its medical providers. 2) Description of how economic profiling is used in Utilization Review (Version 1, 9/16/15) 3

17 Anthem Workers Compensation, LLC ( Anthem ) is not a Utilization Review Organization, Utilization Review Agent, nor involved in any decisions related to a provider s request for authorization (RFA) of treatment. 3) A description of how economic profiling is used in peer review The Practice Habit Profiling used by Anthem Workers Compensation LLC is not utilized in peer review by Anthem. The Peer Review process for UR is a separate function and is presently not performed by Anthem. However, peer review information and profiling may be utilized in Quality Assurance as well as define the inclusion or exclusion of providers from the MPN as described below. 4) A Description of any incentives and penalties used in the program and in provider retention and termination decisions Anthem does not presently have any incentives or penalties as a part of practice profiling. However, intervention may take place if there were egregious indications of medical practice counter to the intent and execution of a quality assurance program. Such intervention would be with the intent of improving patient care, first using provider education to accomplish this goal. If quality of care cannot be changed and improved to an acceptable level for Anthem, the provider may not be retained as an MPN provider, regardless of need for such services, desire of the provider to remain in the MPN, or other factors. Providers with good practice habits are encouraged to be a part of the MPN. Due to the continuous nature of practice monitoring and newly contracted providers submitting bills, providers outside of the MPN may be considered for the MPN. Anthem Workers Compensation, LLC retains the exclusive right per MPN regulations to select or deselect physicians for its MPN per CCR Title 8, Section (c)(4) and (c)(5). (Version 1, 9/16/15) 4