Get a free expo pass for 2018 NWCDC

Free 2018 NWCDC Expo pass.

 

Marquee is offering a free expo pass to our clients for the December NWCDC (National Workers’ Compensation & Disability) Conference & Expo. It’s being held at the Mandalay Bay in Las Vegas on December 5-7. You also have the option of $100 off your premium pass.

To claim your free expo pass or receive the $100 off the premium pass, start here:

Is your MPN working for or against you?

For all dates of injury occurring on or after January 1, 2018, emergency treatment services and medical treatment rendered for a body part or condition that is accepted as compensable by the employer and is addressed by the medical treatment utilization schedule (MTUS) adopted pursuant to Section 5307.7, by a member of the medical provider network or health care organization, or by a physician pre-designated pursuant to subdivision (d) of Section 4600, within the 30 days following the initial date of injury, shall be authorized without prospective utilization review, except as provided in subdivision (c). The services rendered under this subdivision shall be consistent with the medical treatment utilization schedule. In the event that the employee is not subject to treatment with a medical provider network, health care organization, or predesignated physician pursuant to subdivision (d) of Section 4600, the employee shall be eligible for treatment under this section within 30 days following the initial date of injury if the treatment is rendered by a physician or facility selected by the employer. For treatment rendered by a medical provider network physician, health care organization physician, a physician predesignated pursuant to subdivision (d) of Section 4600, or an employer-selected physician, the report required under Section 6409 and a complete request for authorization shall be submitted by the physician within five days following the employee’s initial visit and evaluation.

(c) Unless authorized by the employer or rendered as emergency medical treatment, the following medical treatment services, as defined in rules adopted by the administrative director, that are rendered through a member of the medical provider network or health care organization, a predesignated physician, an employer-selected physician, or an employer-selected facility, within the 30 days following the initial date of injury, shall be subject to prospective utilization review under this section:

(1) Pharmaceuticals, to the extent they are neither expressly exempted from prospective review nor authorized by the drug formulary adopted pursuant to Section 5307.27.

(2) Nonemergency inpatient and outpatient surgery, including all presurgical and postsurgical services.(3) Psychological treatment services.

(4) Home health care services.

(5) Imaging and radiology services, excluding X-rays.

(6) All durable medical equipment, whose combined total value exceeds two hundred fifty dollars ($250), as determined by the official medical fee schedule.

(7) Electrodiagnostic medicine, including, but not limited to, electromyography and nerve conduction studies.

(8) Any other service designated and defined through rules adopted by the administrative director.

Marquee MCS Medical Provider Network Consultative Services in the last 10 years, has saved our clients 20% in total claims costs

Since 2008, we’ve helped California clients develop,  implement and audit customized medical provider networks achieving, on average, a 20% reduction in total claims costs.

Medical Provider Network Benefits:

  • Medical control for the life of a claim
  • Lower utilization review (UR) costs
  • Lower litigation costs
  • Reduced medical/ indemnity expenses
  • Increased return to work frequency

Our staff of knowledgeable professionals understand California’s MPN process and its significant financial benefits. Our service solutions are customizable yet holistic, achieving optimal cost saving outcomes.

Here’s what we do:

  • Conduct a Request for Information (RFI) from qualified Medical Provider Networks, to properly identify most qualified industry participants
  • Launch a formal Request for Proposal (RFP) to both select three finalist candidates based on:
    • Ability to perform listed MPN duties and responsibilities on an annual basis
    • Maintain open lines of communication to program key contacts
    • Provide adequate proof of insurance
    • Offer competitive pricing consideration
  • Perform formal implementation with finalist/selected MPN provider
  • Create MPN service provider guidelines
  • Provide monthly statistics and analytics to client
  • Weekly evaluation and monitoring of the progress and participation of MPN provider

Learn how our MPN services can work for you!

Customized Strategies for Optimal Cost Savings
MARQUEE MANAGED CARE SOLUTIONS
619.881.5510 | P.O. Box 85251, San Diego, CA 92189-5251
© 2017 Marquee Managed Care Solutions, All rights reserved. Legal | Privacy

Is your URO Accredited?

A utilization review process that modifies or denies requests for authorization of medical treatment shall be accredited on or before July 1, 2018, and shall retain active accreditation while providing utilization review services, by an independent, nonprofit organization to certify that the utilization review process meets specified criteria, including, but not limited to, timeliness in issuing a utilization review decision, the scope of medical material used in issuing a utilization review decision, peer-to-peer consultation, internal appeal procedure, and requiring a policy preventing financial incentives to doctors and other providers based on the utilization review decision. The administrative director shall adopt rules to implement the selection of an independent, nonprofit organization for those accreditation purposes. Until those rules are adopted, the administrative director shall designate URAC as the accrediting organization (SB1160). 

Marquee Managed Care Solutions has passed the first phase of this process with our final phase in December 2017.  Let Marquee Managed Care Solutions be your Utilization Review Solution for 2018. 

#marqueemcs

Customized Strategies for Optimal Cost Savings
MARQUEE MANAGED CARE SOLUTIONS
619.881.5510 | P.O. Box 85251, San Diego, CA 92189-5251
© 2017 Marquee Managed Care Solutions, All rights reserved. Legal | Privacy

U.S. Dept. of Health and Human Services Update

On October 1, 2015 The U.S. Department of Health and Human Services (HHS) has mandated the cutover to ICD10 codes from ICD9 codes for any bills that have a Date of Service (DOS) that is 10/1/2015 or later. It has not been mandated in every jurisdiction for workers compensation, but has been adopted by the California Division of Workers’ Compensation. ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list maintained by the World Health Organization (WHO). Originally the implementation date was scheduled in 2014. We have completed changes to our bill review and claims systems in order to be compliant by 10/1/2015. We have received confirmation from our contracted ancillary providers that all bills for the services performed by their providers will be coded and formatted per the regulatory guidelines effective 10/1/2015.

Bills with a date of service prior to 10/1/2015 will be processed using the ICD9 codes. Bills with a date of service on or after 10/1/2015 will utilize ICD10 codes. We will continue to process medical bills and appeals for dates of service prior to 10/1/2015 utilizing the ICD 9 codes.

For additional information regarding the implementation of ICD-10, please refer to www.cms.gov/ICD10.

If you have additional questions about the transition to ICD-10, please contact Marquee Managed Care at 619.881.5510.

Customized Strategies for Optimal Cost Savings
MARQUEE MANAGED CARE SOLUTIONS
619.881.5510 | P.O. Box 85251, San Diego, CA 92189-5251
© 2017 Marquee Managed Care Solutions, All rights reserved. Legal | Privacy

Independent Medical Review – Hidden New Costs to Policyholders?

Independent Medical Review (IMR) was created as part of California Senate Bill 863, which is attempting to reform worker’s compensation law in California. One of the new regulations part of this bill is called Independent Medical Review (IMR). IMR is a process available to injured workers who are dissatisfied with utilization review (UR) decisions in workers’ compensation cases.

As of July 1, 2013, all dates of injury for California workers’ will use an IMR and all disputes will now be resolved by a physician or panel of physicians rather than going through the costly court system. Seemingly a positive service provided to the injured workers, is there a hidden catch?

Who Pays?

The injured worker requesting the IMR does not pay for the review process. Instead, the IMR costs will be paid for by the claims administrator, which will then be passed along to the insurance companies and ultimately the policyholders.

WC Webzine provides their questions on the topic: “Given the expense of this new process, it is questioned whether adjusters will authorize inexpensive procedures like physical therapy or a generic medicine, rather than pay upwards of $600 for IMR. Will frustrated workers be more likely to contact attorneys after getting the UR denial and the confusing IMR Application? Only time will tell.”

There is already an increase in IMR submissions as noted by the DWC, who received 589 IMR applications before July 2013 and by August, the IMRO received 15,731 IMR applications by mail and fax.

Why Change The System?

Under the current system, it typically takes nine to 12 months to resolve a dispute over the treatment needed for an injury. These steps include:

  1. Negotiating over selection of an agreed medical evaluator
  2. Obtaining a panel, or list, of state-certified medical evaluators if agreement cannot be reached
  3. Negotiating over the selection of the state-certified medical evaluator
  4. Making an appointment
  5. Waiting the examination
  6. Awaiting the evaluator’s report, and then if the parties still disagree
  7. Awaiting a hearing with a workers’ compensation judge
  8. Awaiting the judge’s decision on the recommended treatment. In many cases, the treating physician may also rebut or request clarification from the medical evaluator, and the medical evaluator may be required to follow up with supplemental reports or answer questions in a deposition.

SB 863 replaces those eight steps with an IMR process similar to group health that takes approximately 40 (or fewer) days to arrive at a determination so that the appropriate treatment can be obtained.

Although the IMR is intended to help the injured worker, the question must be asked who will ultimately pay for this new service.

For more info about IMR, please visit https://imr.dir.ca.gov/faq.shtml

Customized Strategies for Optimal Cost Savings
MARQUEE MANAGED CARE SOLUTIONS
619.881.5510 | P.O. Box 85251, San Diego, CA 92189-5251
© 2017 Marquee Managed Care Solutions, All rights reserved. Legal | Privacy

MPN Proposed Regulations – SB 863 Changes

A few issues have resulted from the 2004 Workers’ Compensation Reform package from Senate Bill 899. Although the creation of Medical Provider Networks (MPNs) has allowed employers to have better control over treatment for injured workers, employers are concerned that these employees are being given permission to get medical care outside of their MPN. These regulatory breaches are defeating the purpose of SB 899.

Additionally, injured workers are frustrated when they have difficulty scheduling appointments with MPN physicians. Many MPN lists contain physicians who are no longer available or who refuse to treat industrial injuries.

Proposed Changes to MPNs – Senate Bill 863

There are minimal changes proposed for applicants in SB 863. It suggests that an entity that provides physician network services can now also apply to be an MPN applicant.

For established MPNs, substantial changes were suggested.

  • As of January 1, 2013, a contracting agent must inform MPN providers entering or renewing a provider contract that they are part of an MPN whether their contract is sold, leased, transferred or conveyed to another MPN applicant, contracting agent or WC insurer.
  • Medical Access Assistants are required for each MPN to assist workers with finding available MPN physicians and contact physician offices for appointments, and must be available from 7 am-8 pm Pacific Standard Time from Monday through Saturday through a toll-free number.
  • 4-Year Approval: MPN plans will be approved for four years, as of Jan. 1, 2014.
    • Applications for re-approval of existing plans must be submitted six months prior to four-year approval expiration
    • Geocoding of provider listings is required for re-approval
    • Quality Assurance processes must be established for MPNs
  • MPN physicians need to acknowledge that they elect to be part of the MPN, as of January 1, 2014.
  • Each MPN will need to have a website and access to their provider listing on their website as of January 1, 2014:
    • The provider listing must be updated quarterly
    • The Administrative Director will post website addresses for approved MPNs

Administrative oversight changes would include:

  • The Administrative Director can conduct random audits and investigations of MPNs.
  • The Administrative Director can impose penalties, probation, suspension or revocation with the right to appeal to the WCAB Reconsideration Unit.
  • Any person contending that a MPN is not validly constituted may petition the Administrative Director to suspend or revoke the approval of an MPN.

It remains to be seen whether the amendments made to the MPN process by SB 863 will alleviate the issues created from SB 899. However, the WCAB has been quite rigorous in reversing judges who fail to adhere to the new requirement that a violation in MPN regulation must result in a “denial of medical care” in order to allow the injured worker to seek medical care outside of an employer’s MPN.

You can find the comprehensive regulations for MPN’s in Title 8, California Code of Regulations, sections 9767.1 – 9767.16.

If you have questions about SB 863, please contact the Division of Workers’ Compensation (DWC) with the California Department of Industrial Relations, please review their FAQs page or email them at dwc@dir.ca.gov.

Customized Strategies for Optimal Cost Savings
MARQUEE MANAGED CARE SOLUTIONS
619.881.5510 | P.O. Box 85251, San Diego, CA 92189-5251
© 2017 Marquee Managed Care Solutions, All rights reserved. Legal | Privacy