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| California Workers' Comp Reforms—Employee Physician Pre-Designation Tool Kit |
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| By Nancy Decato |
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| With the establishment of Medical Provider Networks, California employers that use best practices to manage the physician pre-designation process have an opportunity to control workers' compensation costs.
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Recent workers' compensation reforms in California gave employers and insurers the opportunity to establish Medical Provider Networks, effective January 1, 2005, for employees injured on the job. Once a network is approved by the California Administrative Director, employees injured at work must use pre-approved network doctors—unless the employee has pre-designated a personal physician.
Although full medical control is ideal, the reality of pre-designation requires that employers communicate medical network benefits and closely manage the pre-designation process. Organizations should begin by developing new policies and procedures. For example, guidelines concerning what constitutes a "personal physician" need to be clearly explained to employees.
Understanding the general rules around medical networks and pre-designation is only the first step. Proactive employers will manage the process from the time of hire through the treatment of an occupational injury. The following describes some employer pre-designation best practices and procedures.
Pre-Designation Guidelines
I. If an employee has notified the employer in writing prior to the date of injury that he or she has a personal physician, the employee has the right to be treated by that physician from the date of injury if their employer provides non-occupational health coverage in a group health plan or group health insurance policy.
II. The criteria for a personal pre-designated physician include the following:
- The physician is the employee's regular physician and surgeon
- The physician is the employee's primary care physician, has previously directed the medical treatment of the employee, and retains the employee's medical records including medical history
- The physician agrees to be pre-designated
- The physician acknowledges that all non-emergency treatment or diagnostic services may be subject to a utilization review
- The physician agrees to comply with the American College Occupational and Environmental Medicine (ACOEM) guidelines for all treatment rendered
Pre-Designation Checklist
By law, the employer is only required to advise employees of their right to predesignate a treating physician. However, forward-thinking employers can proactively manage and validate employee pre-designations by:
- Providing a pre-designation form for all new hires in the new hire orientation program—the form can be obtained from the state, insurer, or claims administrator
- Verifying pre-designations at the time the pre-designation form is submitted rather than waiting until an injury occurs
- Keeping a log of all employees who have pre-designated a personal physician in case of injury
- Requiring the claims administrator to re-verify pre-designation at the time of injury
New Hire Checklist
Employers should develop clear processes to educate new employees on the benefits of the company's managed care network for on-the-job injuries and give new employees the opportunity to pre-designate a treating physician. During the orientation process, employers should:
- Provide on company letterhead the pre-designation form to all new hires and upon request thereafter
- Provide the Notice to New Employees brochure
- Include a checklist in the new hire packet confirming inclusion of the pre-designation form and the Notice to New Employees brochure
- If new hire orientation is done verbally, review the benefits of the employer-sponsored medical network, including doctor choice, specialties, and location. Document that you have explained pre-designation options and procedures as well
- Verify pre-designations upon receipt of written notice of pre-designation
- Discuss pre-designation requirements with the employee if it appears the pre-designation is non-compliant, as defined by the pre-designation guidelines above, and discuss the company's medical provider network
Verification Best Practice
Employers have the opportunity to guide employees through the pre-designation process and verify physician pre-designation without creating conflict. If an employee chooses to pre-designate a physician despite the resources available through the medical network, employers should confirm primary care physician selection for a group health plan and advise the employee of any discrepancies using the following steps:
- Advise the employee that the selected physician must sign the form and he/she must return it to the appropriate department (human resources, risk management, medical, etc.)
- Review the signed Employee Selection of Personal Physician form, making sure the form is completed in full
- Determine whether the employee has designated a primary care physician for group health—human resources or benefits may be required to assist in obtaining this information
- Advise the employee if the pre-designated physician is not part of the group health plan or is not his/her current primary care physician on file, and remind the employee of the company's high-quality and diverse medical network available for workplace injuries
- Advise the employee that he or she cannot pre-designate a chiropractor or acupuncturist based upon the definition of a pre-designated physician
- Contact the designated physician's office to verify the information on the form including:
1. The provider is the employee's regular primary care physician or surgeon who:
a. Has previously directed the medical treatment of the employee (obtain date of last treatment or visit)
b. Retains the employee's medical records including medical history
2. Confirm that the physician agrees to be pre-designated, to comply with a utilization review of all non-emergency treatment, and to adhere to ACOEM guidelines for all treatment rendered
3. Document the process, including the date called and contact name given
4. Verify information and then sign and date the form
- Maintain a record of the employee's selected primary care physician and forward to the claims administrator at the time of a claim if the employee chooses to use a pre-designated physician
Time of Injury Checklist
In the event of an on-the-job injury, employers should:
- Notify the employee of the company's Continuity of Care Policy, which should be drafted by the claims administrator or managed care vendor—policy requirements will be provided by November 1, 2004 from the Administrative Director
- Check the pre-designation log to determine if the employee will seek care in network or with a personal physician
- Promptly provide the claims administrator with all information and documents regarding a pre-designation upon notice of an injury
Updated Materials
Employers are now required to post and regularly update new versions of the Notice to Employees poster as well as use current DWC-1 forms for any workplace incidents reported after August 1, 2004. Additionally, employers must supply all new employees with updated material. Third-party administrators (TPA) or insurers should provide the approved versions of new forms. Employers will have until October 1, 2004 to begin using the new forms without incurring penalties.
Using the correct forms—such as the Notice to Employees Poster, Notice to New Employees (Facts about Workers' Compensation), and the Employee's Claim Form (DWC-1)—and providing employees with the right information about managed care network will help the employer, insurer, and employee take full advantage of the recent reforms, including the pre-designation option.
Updated materials, which are currently available, include:
- Notice to Employees Poster
- Notice to New Employees (Facts About Workers' Compensation)
- Employee's Claim Form (DWC-1)
For more information on the use of these new forms and accompanying regulations or to order materials, please visit the following Web sites:
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