Our News Flash on PPPs Turns into a Dud

Wednesday, January 11, 2012 | 0

This past Tuesday, letters from the Illinois Department of Insurance sent on Dec. 30 were received by three approved workers' compensation preferred provider program providers confirming they were "finally approved."

We assumed final approval meant rock-and-roll, good-to-go, hasta-la-vista baby!!! Instead, we learned it was yet another administrative teaser. At present, our regulators and stat-rats continue to finalize the PPP legislation designed to give Illinois employers that ability to direct medical care and otherwise limit choice of care.

The three PPP administrators approved so far are listed on the Illinois Department of Insurance website and are CorVel Healthcare, Coventry Health Care Workers' Compensation Inc and HFN, Inc. The preferred provider program was authorized as part of House Bill 1698, the workers' compensation overhaul legislation passed by legislators in May and signed into law in June by Gov. Quinn.
 
A PPP is a group of medical providers that has been approved by the employer to treat workers for their injuries. Employers may hire an administrator for the PPP, and the Department of Insurance must approve PPP applications by employers and administrators. Under current law that will not change unless and until all rules and PPP's are in effect, an injured worker was entitled to choose two doctors for treatment, and to receive treatment from any medical providers to whom his doctor referred him.
 
Under HB 1698, if an employer is not enrolled in an approved PPP, an injured worker still will be able to treat with his choice of two doctors and all referrals.

Illinois Employers who are enrolled in workers' compensation PPPs may direct the injured worker's care to medical providers in the network. An employee may opt out of the network at any time upon notice to the employer. However, if an employee does opt out, he is limited to one choice of physician and any referrals by that physician.

An employer using a PPP must provide notice of the availability of the PPP to its workers on a form promulgated by the Illinois Workers' Compensation Commission.
 
Getting the rules in place will require review by the state Legislature's Joint Committee on Administrative Rules (JCAR), which will take at least 150 days after the rules are finalized. The Department of Insurance managers have confirmed the proposed rules should be submitted to the committee this month. JCAR will review the rules and then schedule a public comment period.

This is from the Illinois Department of Insurance website Frequently Asked Questions Regarding Workers' Compensation Preferred Provider Programs.

1. What are the requirements for obtaining approval of the PPP?

Current PPP registration would require each applicant to meet the provisions of:
    a. 215 ILCS 5/370 k (Registration)
    b. 215 ILCS 5/370l (Fiduciary and bonding where applicable)
    c. 215 ILCS 5/370m (Program requirements)
    d. 820 ILCS 305/8.1a(a)(1) (Occupational and non-occupational network adequacy)
    e. 820 ILCS 305/8.1a(a)(2) (Physician and provider network adequacy appropriate for treating injured workers.
    f. 820 ILCS 305/8.1a(a)(4) (Prohibition on inappropriate economic credentialing)
    g. 820 ILCS 305/8.1a(a)(5) (Prohibition against unreasonable discrimination in terms of noninstitutional provider agreements)
    h. 820 ILCS 305/8.1a(b) (Description of any economic evaluation policies and procedures); and i. Applicable sections of 50 IAC 2051 which implement the above referenced statutory references.

2. Are the networks composed of doctors and facilities? Yes. PPP networks may also be specialty networks.

3. Will an employer be allowed to select doctors from a specific group, or will they be forced to select all doctors from a given group when choosing that group? To the extent that an employer desires to directly contract with individual providers (Section 8.1a), they may establish terms and conditions that must be met as long as such terms and conditions do not unreasonably discriminate against or among noninstitutional providers (Section 8.1a(a)(5)).

To the extent that an employer desires to directly contract with a PPP to use a "nested network" (a network which is a smaller component of the whole and such restricted network has been approved by the Department), the employer would also have that statutory flexibility.

4. Do specialty networks, such as pharmacy and physical therapy fall within the PPP? How will these networks be handled? Specialty networks fall within the PPP and will be handled in the same manner as other providers.

5. Will current occupational medicine providers be required to join a PPP in order to qualify as a preferred provider? Yes.

6. What are the requirements for employee notification of the PPP? Is the DOI working with the Commission to establish this form? These requirements are stated in 820 ILCS 305/8(4)(A). The Department of Insurance is cooperating with the Illinois Workers' Compensation Commission in developing the form to be used.

7. What confidentiality restrictions will apply to required PPP filings? PPP filing documents will be handled similarly to other provider network filings with regard to both subpoenaed material and material requested under a Freedom of Information Act request. Section 8.1a(b)(1) of the Workers' Compensation Act requires the Director not to publicly disclose any filed information determined to be confidential, proprietary, or a trade secret.

8. Will provider reimbursement rates be held confidential? Yes.

9. Will a WC PPP administrator be notified when a request is made for a copy of their filing? Not as a routine matter. Such a request would fall under FOIA standards and requirements. (5 ILCS 140/1).

10. How will the Department handle WC PPP renewals? The procedure is outlined in 50 IAC 2051.240 - Registration, Renewals, and Appeals.

11. Will an employer have to register as a WC PPP Administrator if they utilize more than one PPP? Yes, if they are the entity which directly contracts with multiple PPPs.

12. Will PPPs have additional or alternative registration, fiduciary or bonding requirements than those in law and regulation?Not currently.

13. What late payment standards will apply, given that there is one standard in the Insurance Code and another in the Workers' Compensation Act? Standard rules of legislative construction will apply to resolve any apparent conflict.

14. Section 370m(2) requires that notice be given to beneficiaries of "any limitations or exclusions" to coverage. Must notice be given of all possible defenses under the WC Act? No. Disclosures should provide notice to beneficiaries of possible financial liability if their WC claim is determined to be non-compensable.

15. Section 370m(4) requires that notice be given of a complaint procedure. Will there be a required DOI complaint procedure? Notice must be given to beneficiaries of any complaint procedure, if one exists.

16. Section 370m(5) requires disclosure of "deductible and coinsurance" amounts. These don't apply in workers' compensation, what should we do?  If there are none, then there are none to disclose.

17. What will be the parameters used by the Department to define an "adequate number of occupational and non-occupational providers", an "adequate number and type of physicians", "availability and accessibility of care" The Department of Insurance will solicit comments from interested parties and promulgate best practice standards.

18. 50 IAC 2051.280(b) requires that an employee be charged no more in out-of-pocket expenses in the event of necessary out of network care. Will this be applied to PPPs? Yes. Employees should not be penalized for networks that would otherwise be inadequate.

Eugene Keefe is a founding partrner of Keefe, Campbell & Associates, a Chicago workers' compensation defense firm. This column was reprinted with his permission from the firm's client newsletter.