WCL — Article 10-A -- Preferred Provider Organizations
The following highlights the statutory and regulatory provisions relative to Article 10-A of the Workers' Compensation Law. This document is not intended to be inclusive. For greater specificity, the reader is directed to the statute and regulations of the Workers' Compensation Board (Subpart 325-8 of Title 12 NYCRR) and the Department of Health (732-1 and 732-2, of Article 4 of Subchapter C of Chapter V of Title 10 of the Official Compilation of Codes, Rules and Regulations of the State of New York).
Chapter 635 of the Laws of 1996 authorized a number of initiatives intended to reform the current New York State Workers' Compensation System. This reform legislation modifies the New York State Workers' Compensation Law to authorize the insurance carriers and self-insured employers to contract with NYS Department of Health certified preferred provider organizations (PPOs) to provide services to diagnose, treat and rehabilitate a claimant requiring medical treatment of an occupational disease or injury.
Who May Apply to Become a PPO
Any plan or entity with the ability to establish a network of medical providers to treat all services covered under the WCL may apply for preferred provider organization (PPO) certification. No insurer or employer shall have any financial interest in the PPO.
How to Apply
- The Department of Health is responsible for the development, implementation and administration of a process for the certification and monitoring of participating PPOs.
- To apply for certification, contact Guy Boretti, Program Manager, NYS Department of Health, Corning Tower, Empire State Plaza, Albany, N. Y. 12237, (518) 474-5515.
- The application for PPO certification, shall be accompanied by a $500 application fee.
Documentation Required for Certification
- List and addresses of members of the governing body of the PPO which will be responsible for establishment of the PPOs policies, management and overall operation, including responsibility for adoption and enforcement of all policies governing health care services delivery, quality assurance and improvement, utilization review and all other PPO operations.
- Certificate of Incorporation or proposed Certificate of Incorporation, bylaws, partnership agreement, and application for authority to do business in New York.
- Independently audited financial statement of applicant.
- Demonstration of character, competence, experience, and community standing of the medical director, members of the board, officers, owners, shareholders, and partners of the PPO.
- Selection standards for participating providers.
- Names and credentials, authorization to treat workers' compensation, licensing and certification requirements, and description of any final dispositions of professional misconduct for each provider/facility.
- A description of times, places and manner of providing services under the PPO.
- Procedures for ongoing Quality Assurance.
- Procedures for Utilization Review consistent with Article 49 or a nationally recognized accrediting entity.
- Procedures for Dispute Resolution consistent with Section 4408-A and Article 49 of the Public Health Law.
- A description of how the PPO will meet the provider network criteria requirements.
- Urban counties are required to have at least 1 Acute Care Hospital within the county and at least 1 other Acute Care Hospital available in contiguous counties. Rural counties should contain an Acute Care Hospital for claimant 40 miles or less within access of claimant's worksite or home. If not available in PPO, claimant has right to treat at nearest Acute Care Hospital.
- PPO must ensure that at least two medical or health care providers will be made available in
each county to claimants in each area of specialization required or offered, or:
- document that there are not at least two physicians in a particular specialty in each country within the service area; and
- document that there are at least two of the following specialty physicians under contract within each country within the proposed service area: family practice (board certified GP); orthopedic surgery, neurology, internal medicine; physical therapist; chiropractor and surgeon, and
- document that there are at least two of the following specialty physicians under contract within a county or counties contiguous to one or more of the other counties which comprise the service area: anesthesiology, physical medicine and rehabilitation; psychiatry; psychology; radiology and dermatology; and
- document that there are at least two of the following specialty physicians under contract within the Workers' Compensation Board district office service area: cardiology; pulmonary disease; ophthalmology; hand surgery; pathology; plastic surgery; urology; podiatrist; occupational therapist; neurological surgery; otolaryngology; thoracic surgeon; allergy and immunology; or
- documentation indicating that the standards contained in subparagraphs listed above, cannot be met along with documentation, acceptable to the Commissioner, in consultation with the Chair, indicating how the PPO will provide claimants with an equivalent and accessible choice of practitioners.
General Organizational and Operating Requirements
- PPO shall have a governing body which will be responsible for establishment and oversight of the PPOs policies, management and overall operation.
- PPO shall employ an administrator who shall be responsible for overseeing all facets of the operation.
- PPO shall employ a medical director responsible for oversight of all aspects of medical care including the quality and appropriate utilization of services and development, updating and assurance of compliance with medical standards.
- A PPO may enter into a management contract with an entity to oversee the management of the day to day activities of the PPO with respect to the performance of various services including: management information systems, utilization review, payment and medical dispute resolution and quality assurance. However, any such contract shall be effective only with the prior written consent to the Commissioner. A PPO may not enter into a management contract with a self-insured employer, an insurance carrier or with any entity owned or controlled by, or affiliated with such carrier to oversee the management of the day to day activities of the PPO with respect to the performance of quality assurance and medical dispute resolution.
- PPO shall ensure access and availability to emergency care 24 hours a day.
- PPO shall ensure access to initial treatment for all non-emergency care within 48 hours.
- PPO shall develop and ensure a system which employees may obtain information on a 24 hours a day basis regarding the availability of medical services and emergency services.
- PPO shall develop and require provider adherence to treatment standards and protocols.
- The PPO shall maintain a return to work program in conjunction with the employer, treating physician and carrier to facilitate the return of injured workers to the workplace.
A PPO shall not be required to reimburse for provider services in accordance with the provider fee schedules authorized pursuant to the Workers' Compensation Law. (Inpatient hospital fees are not negotiable, but tied to the Medicaid rate).
Decertification of a PPO
- If the PPO does not meet compliance with the regulations, the Commissioner may revoke or suspend certification.
- If the Commissioner deems that the PPO noncompliance was unintentional, a plan of correction may be requested. If plan of correction is carried out to the Commissioner's satisfaction, decertification will not occur.
- If the PPO supplies false information in its application, the Commissioner may revoke or suspend certification.
- Decertification of a PPO will be effective for three years and preclude the organization from operating or being affiliated in any manner with a certified PPO.
Records, Reports and Information Requirements of the PPO
- Clinical record shall be made available to the Commissioner by the PPO.
- The PPO shall report to the Commissioner information regarding disciplinary action against any provider or information regarding professional misconduct.
- All other business records and data management by the PPO, and relevant to the Commissioner's authority to oversee the activities of the PPO and to determine the appropriateness of the continued certification, shall be made available upon request.
- PPO shall develop a detailed plan for providing affected employees with written notice of the PPO arrangement for the treatment of all workers' compensation injuries and illness.
- The PPO shall develop a handbook to distribute to employers who will in turn distribute to employees on an as needed basis. The handbook shall contain all information needed by an employee to access services, the procedures for selecting and changing providers within the PPO network, a full explanation of all rights and responsibilities of the PPO, employer and employee when services are required, a detailed description of the policies and procedures of the PPO including utilization review, a description of the opt-out procedures for the employee, a description of the process for obtaining a second opinion, and a listing of all participating providers, including address, telephone number and their specialties.
- If a provider ceases participation in the PPO, or if any provider becomes unavailable to provide services to any claimant, the PPO shall provide written notice to affected claimants within fifteen (15) days from the date that the organization becomes aware of such change in status. Such notice shall also include the procedures for choosing an alternate provider within the PPO and steps to be taken to ensure continuity of care.
- PPOs must submit full and truthful reports of their findings to the employer and the Workers' Compensation Board. Providers who misrepresent their findings will have their WCB authorization revoked.
Opt-outs, Second Opinions
- PPO shall make claimants aware of their right to opt-out of PPO care and seek medical treatment from outside the PPO. The right to opt-out is per injury.
- The employee may seek medical treatment from a provider outside of the PPO network only after 30 days from the date of their initial visit to a PPO provider.
- The employer has the right to require a second opinion from a provider within the PPO.
- The PPO shall permit the claimant to choose treatment for occupational disease from the NYS Occupational Health Clinics Network.
Notice and Approval Required to Discontinue Operation
PPO shall provide at least 90 days written notice to each participating carrier or self-insured employer, the Commissioner of Health, and the Workers' Compensation Board Chair, before voluntarily discontinuing operations.
Where there is a duty to collectively bargain for the utilization of a PPO, an employer must engage in such bargaining and must file with the Workers' Compensation Board a notarized affirmation signed by the collective bargaining agent(s) confirming that the requisite negotiation has taken place and that the particular union and individual agent(s) which have agreed to such PPO, are the recognized or certified exclusive bargaining representatives of the covered employees.
All carriers and self-insured employers who have contracted with PPOs for the treatment of workers' compensation injuries, shall report to the Chair of the Workers' Compensation Board, the names and addresses of insured employers who have elected to utilize the PPO and specified data pertaining to utilization, quality of care, costs and outcomes.
For information contact
Director, Bureau of Health Management
Workers' Compensation Board
100 Broadway - Menands
Albany, NY 12241
Employees must seek initial treatment from the PPO and may opt-out only after 30 days from the initial visit.