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California Division of Workers' Compensation (DWC) Clarifies Provider Directory Requirements for Medical Provider Networks
By Lonce Lamonte and the California DIR Newsline - July 20, 2022

The Division of Workers’ Compensation (DWC) has received questions regarding the types of entities or companies that can be included in a Medical Provider Network (MPN) provider directory. The provider directory lists licensed physicians and ancillary providers of medical services (such as physical therapists) from which an injured worker covered by the MPN can freely select as their provider of medical treatment.  DWC would like to ensure that MPNs submitting provider listings to the Division for approval do not include non-compliant provider names.

Under current law, if an MPN submits a provider listing that contains the names of non-professional organizations, management services organizations, scheduling and coordinating companies, cost containment companies, or other non-provider entities, the DWC will disapprove the MPN submission. For example, if an MPN submission includes an ancillary service provider, such as a non-professional corporation that either schedules or provides physical therapy, the submission will be denied since the entity cannot legally render professional services. See Business and Professions Code § 2406.

DWC will approve MPN submissions that contain the names of licensed providers (Labor Codes §§ 3209.3 and 3209.5), the names of professional corporations that can legally render medical services under the corporate name (Corporation Code § 13400 et seq.), or the names of licensed health care facilities (Health and Safety Code § 1250).

Upon submission of an MPN Plan to the DWC for review, MPNs are required to affirm under penalty of perjury that all of the physicians listed have a valid and current license number to practice in the state of California (California Code of Regulations, title 8, § 9767.3(c)(2)), and that all of the ancillary service providers listed have a current valid license number or certification to practice by the State of California and can provide the requested medical services or goods (California Code of Regulations, title 8, § 9767.3(c)(3)). These regulations make it clear that MPNs are responsible for credentialing ALL of the providers in their MPN provider listing.

Finally, if an MPN is uncertain about the legal status of an entity that they are thinking of listing, an available option is to list the names of each individually licensed provider rather than the questionable entity name. This ensures statutory and regulatory compliance and a robust MPN provider listing from which injured workers can freely choose their providers..

 

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by Lonce Lamonte, editor, and the DWC Newsline.  July 20, 2022

 
 

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