Bill Text: CA SB914 | 2015-2016 | Regular Session | Chaptered
Bill Title: Workers' compensation: medical provider networks: independent medical reviews.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2016-07-22 - Chaptered by Secretary of State. Chapter 84, Statutes of 2016. [SB914 Detail]
Download: California-2015-SB914-Chaptered.html
BILL NUMBER: SB 914 CHAPTERED
BILL TEXT
CHAPTER 84
FILED WITH SECRETARY OF STATE JULY 22, 2016
APPROVED BY GOVERNOR JULY 22, 2016
PASSED THE SENATE APRIL 11, 2016
PASSED THE ASSEMBLY JUNE 30, 2016
INTRODUCED BY Senator Mendoza
JANUARY 26, 2016
An act to amend Section 4616.4 of the Labor Code, relating to
workers' compensation.
LEGISLATIVE COUNSEL'S DIGEST
SB 914, Mendoza. Workers' compensation: medical provider networks:
independent medical reviews.
Existing law establishes a workers' compensation system,
administered by the Administrative Director of the Division of
Workers' Compensation, to compensate an employee for injuries
sustained in the course of his or her employment. Existing law
authorizes an insurer, employer, or entity that provides physician
network services to establish or modify a medical provider network
for the provision of medical treatment to injured employees, and
requires the administrative director to contract with individual
physicians or an independent medical review organization to perform
medical provider network independent medical reviews. Existing law
provides that if a treatment or diagnostic service remains disputed
after a 3rd physician's opinion, the injured employee may request a
medical provider network independent medical review. Existing law
requires the review to use standards established in statute or use
the American College of Occupational and Environmental Medicine's
Occupational Medicine Practice Guidelines.
This bill would delete the authorization to use the American
College of Occupational and Environmental Medicine's Occupational
Medicine Practice Guidelines as standards for those independent
medical reviews. The bill would make additional technical,
nonsubstantive changes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 4616.4 of the Labor Code is amended to read:
4616.4. (a) (1) The administrative director shall contract with
individual physicians, as described in paragraph (2), or an
independent medical review organization to perform medical provider
network (MPN) independent medical reviews pursuant to this section.
(2) Only a physician licensed pursuant to Chapter 5 (commencing
with Section 2000) of the Business and Professions Code may be an MPN
independent medical reviewer.
(3) The administrative director shall ensure that an MPN
independent medical reviewer or those within the review organization
shall do all of the following:
(A) Be appropriately credentialed and privileged.
(B) Ensure that the reviews provided by the medical professionals
are timely, clear, and credible, and that reviews are monitored for
quality on an ongoing basis.
(C) Ensure that the method of selecting medical professionals for
individual cases achieves a fair and impartial panel of medical
professionals who are qualified to render recommendations regarding
the clinical conditions consistent with the medical utilization
schedule established pursuant to Section 5307.27.
(D) Ensure that confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
(E) Ensure the independence of the medical professionals retained
to perform the reviews through conflict-of-interest policies and
prohibitions, and ensure adequate screening for conflicts of
interest.
(4) A medical professional selected by the administrative director
or the independent medical review organization to review medical
treatment decisions shall be a physician, as specified in paragraph
(2) of subdivision (a), who meets the following minimum requirements:
(A) The medical professional shall be a clinician knowledgeable in
the treatment of the employee's medical condition, knowledgeable
about the proposed treatment, and familiar with guidelines and
protocols in the area of treatment under review.
(B) Notwithstanding any other law, the medical professional shall
hold a nonrestricted license in any state of the United States, and
for a physician, a current certification by a recognized American
medical specialty board in the area or areas appropriate to the
condition or treatment under review.
(C) The medical professional shall have no history of disciplinary
action or sanctions, including, but not limited to, loss of staff
privileges or participation restrictions taken or pending by any
hospital, government, or regulatory body.
(b) If, after the third physician's opinion, the treatment or
diagnostic service remains disputed, the injured employee may request
an MPN independent medical review regarding the disputed treatment
or diagnostic service still in dispute after the third physician's
opinion in accordance with Section 4616.3. The standard to be
utilized for an MPN independent medical review is identical to that
contained in the medical treatment utilization schedule established
in Section 5307.27.
(c) An application for an MPN independent medical review shall be
submitted to the administrative director on a one-page form provided
by the administrative director entitled "MPN Independent Medical
Review Application." The form shall contain a signed release from the
injured employee, or a person authorized pursuant to law to act on
behalf of the injured employee, authorizing the release of medical
and treatment information. The injured employee may provide any
relevant material or documentation with the application. The
administrative director or the independent medical review
organization shall assign the MPN independent medical reviewer.
(d) Following receipt of the application for an MPN independent
medical review, the employer or insurer shall provide the MPN
independent medical reviewer, assigned pursuant to subdivision (c),
with all information that was considered in relation to the disputed
treatment or diagnostic service, including both of the following:
(1) A copy of all correspondence from, and received by, any
treating physician who provided a treatment or diagnostic service to
the injured employee in connection with the injury.
(2) A complete and legible copy of all medical records and other
information used by the physicians in making a decision regarding the
disputed treatment or diagnostic service.
(e) Upon receipt of information and documents related to the
application for an MPN independent medical review, the MPN
independent medical reviewer shall conduct a physical examination of
the injured employee at the employee's discretion. The MPN
independent medical reviewer may order any diagnostic tests necessary
to make his or her determination regarding medical treatment.
Utilizing the medical treatment utilization schedule established
pursuant to Section 5307.27, and taking into account any reports and
information provided, the MPN independent medical reviewer shall
determine whether the disputed health care service was consistent
with Section 5307.27 based on the specific medical needs of the
injured employee.
(f) The MPN independent medical reviewer shall issue a report to
the administrative director, in writing, and in layperson's terms to
the maximum extent practicable, containing his or her analysis and
determination whether the disputed health care service was consistent
with the medical treatment utilization schedule established pursuant
to Section 5307.27, within 30 days of the examination of the injured
employee, or within less time as prescribed by the administrative
director. If the disputed health care service has not been provided
and the MPN independent medical reviewer certifies in writing that an
imminent and serious threat to the health of the injured employee
may exist, including, but not limited to, serious pain, the potential
loss of life, limb, or major bodily function, or the immediate and
serious deterioration of the injured employee, the report shall be
expedited and rendered within three days of the examination by the
MPN independent medical reviewer. Subject to the approval of the
administrative director, the deadlines for analyses and
determinations involving both regular and expedited reviews may be
extended by the administrative director for up to three days in
extraordinary circumstances or for good cause.
(g) The MPN independent medical reviewer's analysis shall cite the
injured employee's medical condition, the relevant documents in the
record, and the relevant findings associated with the documents or
any other information submitted to the MPN independent medical
reviewer in order to support the determination.
(h) The administrative director shall immediately adopt the
determination of the MPN independent medical reviewer, and shall
promptly issue a written decision to the parties.
(i) If the determination of the MPN independent medical reviewer
finds that the disputed treatment or diagnostic service is consistent
with Section 5307.27, the injured employee may seek the disputed
treatment or diagnostic service from a physician of his or her choice
from within or outside the medical provider network. Treatment
outside the medical provider network shall be provided consistent
with Section 5307.27. The employer shall be liable for the cost of
any approved medical treatment in accordance with Section 5307.1 or
5307.11.
