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Glossary of WCB Terms

Preferred Provider Regulations


A new Subpart 325-8 of Title 12 NYCRR is added to read as follows:

SUBPART 325-8 - PREFERRED PROVIDER ORGANIZATION ARRANGEMENTS

Section 325-8.1. Preferred provider organization treatment; alternative care

Subject to the duty to collectively bargain, all employees of an employer who has elected to utilize its workers' compensation insurance carrier's selected preferred provider organization shall obtain initial treatment from such preferred provider organization. Any employee may seek treatment from outside of the preferred provider organization thirty days after his or her initial treatment from a preferred provider organization provider.

Section 325-8.2. Employers' responsibilities

  1. Any employer utilizing the services of a certified preferred provider organization shall distribute to all of its employees a written notice of the preferred provider organization arrangement for the treatment of all workers' compensation injuries and illnesses. Such written notice shall also advise potential claimants that they may obtain more detailed informational materials regarding the preferred provider organization from the employer.
  2. Where there is a duty to collectively bargain for the utilization and implementation of a preferred provider organization, an employer must engage in such bargaining and must file with the board a notarized affirmation adobe pdf signed by the collective bargaining agent(s) confirming that the requisite negotiation of the selection of a preferred provider organization has taken place and that the particular union and individual agent(s) which have agreed to such preferred provider organization are the recognized or certified exclusive bargaining representatives of the covered employees. All agreements shall clearly state the duration of such agreement and all subsequent agreements shall be subject to the same prior review and approval by the collective bargaining agent(s).

Section 325-8.3. Preferred provider organization providers' responsibilities

Preferred provider organization providers must submit full and truthful reports of their findings to the employer and the board. Providers who improperly alter or edit their reports or otherwise misrepresent their findings to the employer or the board will have their authorization revoked by the chair in accordance with sections 13-d, 13-k, 13-l and 13-m of the workers' compensation law.

Section 325-8.4. Reporting requirements

All insurance carriers and self-insured employers who have contracted with a preferred provider organization for the treatment of workers' compensation injuries and illnesses shall report to the chair the names and addresses of insured employers who have elected to utilize the preferred provider organization. As required by the chair, such carriers and self-insured employers shall also report to the chair, in a prescribed format, specified data pertaining to utilization, quality of care, costs and outcomes.

Section 325-8.5 Improper Influence or Involvement in Medical Treatment

  1. No person, including but not limited to the employer, insurance carrier, self-insured employer or any of their agents shall interfere with the selection by an injured employee of an authorized physician for treatment except as authorized by Article 10-A, Section 354 of the Workers' Compensation Law nor shall any insurer, carrier or self-insured employer improperly influence or attempt to improperly influence the medical opinion of any physician who has treated or examined an injured employee within the meaning of Section 13-a(6) of the Workers' Compensation Law.
  2. No insurer, carrier or self-insured employer shall take any action which may constitute an attempt to participate in the treatment of an injured employee within the meaning of Section 13-j(l) of the Workers' Compensation Law.
  3. All functional activities which are subcontracted by a PPO through a management contract arrangement in accordance with Part 732-2.5(b) of 10 NYCRR, including case management services, as defined by the parties to the management contract, shall conform to the provisions of Section 13-a(6) and 13-j(l) of the Workers' Compensation Law. Copies of all management contracts shall be provided to the chair as well as the Commissioner of Health for compliance purposes. Where necessary, the chair or the Commissioner of Health shall seek additional information from insurers, carriers and self-insured employers who enter into such arrangements with PPOs to ensure compliance with this Part.

Section 325-8.6. Applicability of board rules and regulations

All rules and regulations of the chair and the workers' compensation board with respect to the rights, duties and obligations of employees, employers, insurance carriers, and authorized providers under the workers' compensation law are expressly made applicable to preferred provider organization arrangements except to the extent that such rules and regulations are inconsistent with Article 10-A adobe pdf of the workers' compensation law or the rules and regulations promulgated pursuant to Article 10-A adobe pdf of the workers' compensation law.