NOTIFICATION TO USC EMPLOYEES OF MEDICAL PROVIDER NETWORK

Employee’s Rights & Responsibilities

You have the responsibility to:

• Report promptly any work related injury or sickness to your supervisor

• Be cooperative and courteous with the Medical Care Coordinator, Primary Care       Physician,  Specialist Physician, Nurse Case Manager, Claims Examiner, and USC personnel

• Ensure all treatment is received from the Medical Provider Network, except in the case of an emergency

• Keep all appointments

• Return to work as soon as your doctor says you can

You have the right to:

• Prompt, quality medical care for your workplace injury

• Be treated courteously by your Medical Care Coordinator, Primary Care Physician, Specialist Physician, Nurse Case Manager, Claims Examiner, and USC personnel

• You may change physicians within the MPN as many times as you wish

• Request a second medical opinion if you dispute the diagnosis or treatment plan

• Request a third medical opinion if you are not in agreement with the Second Medical opinion

• Request an Independent Medical Review from the Administrative Director if you are not satisfied with the third medical opinion.

• Have all questions related to your medical care and claim answered in a manner you

     understand

Commonly Asked Questions

(1) How was USC’s Medical Provider Network chosen?

USC has two criteria for choosing providers for its MPN:  They must be able to deliver quality medical care, and they must be convenient for our employees.  

(2) Who are the core providers in the MPN?

Because many of our employees are enrolled in Kaiser Permanente for their group health coverage, we chose Kaiser’s occupational clinics, called “Kaiser on the Job” as one of our core MPN providers.

Because many of our employees are enrolled in the USC Network PPO for their group health coverage, we chose the USC Physicians Group as another core provider.

We also chose US HealthWorks Medical Group, an occupational clinic adjacent to the UPC campus, for their expertise and convenient location.

(3) What types of medical providers are in the MPN?

The MPN is quite large, with over 1,000 providers.  It consists of many different specialists, plus ancillary providers such as chiropractors, acupuncturists, physical therapists, radiologists, etc. 

(4) Will the MPN be changed in the future?

Medical providers may be added to, and possibly deleted from, the MPN at various times.

(5) When is USC required to provide employees Notification of the MPN?

The first notification will go to all employees prior to the time the MPN implemented.   All employees currently treating with non-MPN physicians who are transferred into the MPN will receive the notification.   All new hires will receive the Notification.  All employees who experience a work-related injury or illness will receive the notification.   All notifications will be in English and Spanish.

(6) What services does the MPN offer?

All treatment and diagnosis of injuries or illnesses will be provided by physicians and other designated providers within the MPN. Providers within the MPN will follow all applicable medical treatment guidelines and we will allow covered employees a choice of providers in the network after the first visit. The MPN will also offer an opportunity for second and third opinions if you disagree with the diagnosis or treatment offered by the treating physician. Any ancillary services, such as radiology or physical therapy, needed to augment the diagnosis and treatment of injuries/illnesses will be obtained through a service provider designated in the MPN plan.

(7) What do I need to do if I am injured, or become ill, as a result of my job?

As with any work-related accident or illness, the first thing you should do is notify your supervisor.  You will then see a medical provider for your initial visit based on your work location as per the below table.  No appointment will be necessary. 

Except in cases of pre-designated physicians, medical emergencies, transfer of care and continuity of care situations, please keep in mind that you are required to use an MPN physician for all work related injuries and illness. You will see information below about pre-designated physicians, transfer of care and continuity of care situations.

(8) How can I review, receive, or access the MPN provider directory?

• You can receive the MPN provider directory by calling the USC Workers’ Compensation Department at 213-740-6205
• You can access and review the MPN provider network by going to the USC Career and Protective Services Website at http://capsnet.usc.edu.  Click on “Workers’ Compensation” and then on “MPN Provider Network”.
• You can receive, access and review the MPN Provider Network by going to the USC Workers’ Compensation Department office at 851 Downey Way, Hazel Stanley Hall Building, Room 300, on the University Park Campus.

(9) What if my employer disputes my injury?

You may be entitled to receive treatment even if your employer initially disputes your work-related injury. Until the date the claim is rejected, the employer’s liability for the claim shall be limited to ten thousand ($10,000) dollars, but this does not guarantee that you will receive medical care up to this ten thousand dollar limit. Treatment can continue until the employer makes a decision to deny your claim. This treatment is still within the MPN.

(10) If the injury is minor, do I still have to report it?

Yes, any injury, no matter how small, should be brought to your supervisor's attention immediately. Without proper medical attention, even a simple situation could lead to complications.

(11) Can I treat with my personal physician if I properly pre-designate him or her prior to the injury?

Yes, you may treat with your personal physician outside the MPN if you properly pre-designate him or her prior to the injury.  As per California Labor Code Section 4600 a “personal physician” must meet the following conditions:

• A “personal physician” is the employee’s regular physician or surgeon, licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. 
• A personal physician must be your primary care provider and have previously directed your medical treatment and retain your medical records, including your medical history.

Also,

• The physician must agree to be pre-designated.
• USC must be notified of the pre-designation in writing prior to the injury.
• The employer must offer group health coverage (which USC does).

(12) How do I choose a physician within the MPN to obtain initial or subsequent medical care?

Report any work-related injury to your supervisor.   Once you report the incident, go to the nearest medical facility for your initial evaluation.   See the above table to determine which medical provider to see.   At any point in time after the initial medical evaluation with an MPN physician you may select a physician of your choice from within the MPN.  Selection of a treating physician and any subsequent physicians must be based on the physician’s specialty or recognized expertise in treating the particular injury or condition in question.  There are several ways to obtain a list of physicians from which to choose :

• You may access the network via the internet at http://capsnet.usc.edu.     
• You may contact your claims examiner at Sedgwick CMS by calling 800-854-6188.
• You can call the USC Workers’ Compensation Department at 213-740-6205.

By choosing a network physician, you are assured the treatment for your occupational injury or illness is appropriate. Once you choose a physician within the MPN, please call the physician and advise him or her of your personal information, employer name, and that Sedgwick CMS is the third party administrator for USC.

(13) What do I do if I experience trouble obtaining an appointment within the MPN?

Please contact your claims examiner at 800-854-6188 if you experience difficulty in scheduling an appointment or obtaining treatment with a provider within the MPN. You may also call the USC Workers’ Compensation Department at 213-740-6205.

(14) Must I use approved MPN physicians and facilities?

Yes, under state law all medical care (except in cases of pre-designated physicians, emergencies, transfer of care and continuity of care situations) resulting from a work-related injury or illness must be handled through a provider in the MPN, unless there are not an adequate number of providers in accessible locations in all medical specialties. Information regarding pre-designated physicians is set forth above. Below is information about transfer of care and continuity of care situations.

(15) What if I need a specialist, such as an orthopedic physician?

If your MPN treating physician cannot provide you the care needed to cure or relieve you from the effects of your work related injury, you will be referred to an MPN specialist that is appropriate for your injury. Your claims examiner and nurse case manager can also assist in finding an appropriate network physician.

(16) If I'm hurt or become ill while traveling on business, what do I do?

Should you require medical treatment for a work-related accident or illness while outside of the MPN area (i.e., while on a business trip), DO NOT delay treatment until returning home. Your health and welfare are the most importance issue.   Seek medical attention where you are.  When you return home, we will then refer you to an MPN physician.  Make sure you notify your supervisor immediately of the injury.

(17) What do I do in an emergency situation?

Naturally, you are not expected to contact your supervisor prior to receiving medical treatment in a life-threatening situation. Once you've received the emergency medical care required, you (or a family member) should contact your supervisor. Your supervisor will then contact the USC Workers’ Compensation Department, who will work with the treating doctor. This coordination will continue when you return home.

(18) What if I have a concern with my physician?

Your input is very important. You may voice a concern by calling your claim examiner or nurse case manager at 800-854-6188. They will work with you to resolve your issue with the physician. You may also contact the USC Workers’ Compensation Department at 213-740-6205.

(19) What if I disagree with the treatment plan and diagnosis made by my physician?

If you dispute either the diagnosis or the treatment prescribed by the treating physician, you may obtain a second and, if necessary, a third opinion from physicians within the MPN. During this process, you are required to treat with your original treating physician.  

Second Opinion

The procedure for obtaining a second opinion within the MPN is as follows:

It is your responsibility to:

• inform the claims examiner or nurse case manager that you dispute the treating physician’s opinion and request a second opinion;
• select a physician or specialist from a list of available MPN providers;
• make an appointment with the second opinion physician within 60 days and indicate whether a physical examination is requested.  If you do not make an appointment within 60 days of receipt of the list of the available MPN providers, then you will be deemed to have waived the second opinion process with regard to this disputed diagnosis or treatment of this treating physician.
• inform your claims examiner of the appointment date.

It is the claims examiner’s responsibility to:

• provide a list of MPN providers and/or specialists to you based on the specialty or recognized expertise in treating the particular injury or condition in question;
• contact the treating physician, provide a copy of the medical records prior to the appointment date, and provide a copy of the records to you; and
• notify the second opinion physician in writing that he or she has been selected to provide a second opinion and the nature of the dispute.

If, after reviewing your medical records, the second opinion physician determines your injury is outside the scope of his or her practice, the physician shall notify the claims examiner in order that a new list of MPN providers and/or specialists to the employee for his/her selection based on the specialty or recognized expertise in treating the particular injury or condition in question can be provided.

Third Opinion

If you disagree with either the diagnosis or treatment plan prescribed by the second opinion physician, you may seek the opinion of a third physician within the MPN.  The procedure is a follows:

It is your responsibility to:

• inform the claims examiner that you dispute the treating physician’s opinion and request a third opinion;
• select a physician or specialist from a list of available MPN providers;
• make an appointment with the third opinion physician within 60 days and indicate whether a physical examination is requested.  If the appointment is not made within 60 days of receipt of the list of the available MPN providers, then you will be deemed to have waived the third opinion process with regard to this disputed diagnosis or treatment of this treating physician.
• inform your claims examiner of the appointment date

It is the claims examiner’s responsibility to:

• provide a list of MPN providers and/or specialists to you for your selection based on the specialty or recognized expertise in treating the particular injury or condition in question;
• contact the treating physician, provide a copy of your medical records to the third opinion physician prior to the appointment date and provide a copy of the records to you;  
• notify the third opinion physician in writing that he or she has been selected to provide a third opinion and the nature of the dispute.

If, after reviewing the covered employee’s medical records, the third opinion physician determines that your injury is outside the scope of his or her practice, the physician shall notify the claims examiner in order that a new list of MPN providers and/or specialists can be sent to you based on the specialty or recognized expertise in treating the particular injury or condition in question.

The second and third opinion physician shall render his or her opinion of the disputed diagnosis or treatment in writing and offer alternative diagnosis or treatment recommendations, if applicable. Any recommended treatment shall be in accordance with Labor Code section 4616(e). The second and third opinion physician may order diagnostic testing if medically necessary. A copy of the written report shall be served on the employee and the person designated by USC within 20 days of the date of the appointment or receipt of the results of the diagnostic tests, whichever is later.

(20) What if I disagree with the diagnosis or treatment of the third opinion physician?

Upon your requesting a third opinion, you will receive a letter from your claims examiner advising you of your right to request, pursuant to Labor Code Section 9768,  an Independent Medical Review in the event you disagree with the diagnosis or treatment plan of the third opinion physician.  Included with that letter will be a state-approved form for making the request to the Administrative Director.

If the determination of the independent medical reviewer finds that the disputed treatment or diagnostic service is consistent with Labor Code Section 5307.27 or the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines, you may seek the disputed treatment or diagnostic service from a physician of your choice from within or outside the medical provider network.

(21) How do I request an Independent Medical Review?

Upon requesting a third opinion, your claims examiner will send you a letter advising you of your right to request an Independent Medical Review should you disagree with the diagnosis or treatment plan of the third opinion physician.   Along with this letter will be a state-approved form to be used when requesting an Independent Medical Review and instructions on how to make the appeal.

(22) What if at any time I feel I need help from the Administrative Director?

You may contact the Information and Assistance Officer at your local Workers’ Compensation Appeals Board. Your claims examiner will give you the telephone number of the officer nearest you.

(23) Who should I contact if I have questions regarding the MPN?

Please contact the USC Workers’ Compensation Department at 213-740-6205 or your claims examiner at 800-854-6188 if you have trouble getting an appointment or appropriate medical care.

The official Designated MPN Contact listed with the State of California is:

Mr. Doug Moore

Executive Director,

Risk Management

University of Southern California

851 Downey Way, HSH 300

Los Angeles, CA 90089-1058

213-740-6201 Phone

213-740-7305 Fax

You may call this person with any questions, problems or concerns about the MPN.

What is Continuity of Care?

Continuity of care is explained in the attached continuity of care policy.

What is Transfer of Care?

Transfer of care is explained in the attached transfer of care policy.

Continuity of Care Policy

(1) “Continuity of Care” refers to a situation where an MPN physician, with whom a USC employee is treating, for some reason is no longer in the MPN (a “terminated” physician).  USC must then provide for continuation of care for the employee – in other words, decide how the medical care of that employee is to be handled.   The state requires that we have a written policy discussing how this will be accomplished.   It is USC’s intention to have our employees continue their care with physicians in the MPN, except for in the following situations:   

• An acute condition:   a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of treatment shall be provided for the duration of the acute condition.

• A serious chronic condition:  a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time, or requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider as determined by USC in consultation with the injured employee and the terminated provider and consistent with good professional practice. Completion of treatment under this paragraph shall not exceed 12 months from the contract termination date.

• A terminal illness:   an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of treatment shall be provided for the duration of a terminal illness.

• Performance of a surgery:   a procedure that is authorized by USC as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contract's termination date.

(2) USC may require the terminated provider whose services are continued beyond the contract termination date to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, then USC is not required to continue the provider’s services beyond the contract termination date.

(3) Unless otherwise agreed to by the terminated provider and USC, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by USC for currently contracting providers providing similar services who are practicing in the same or a similar geographic area as the terminated provider. USC is not required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.

(4). This policy shall not require USC to provide for completion of treatment by a provider whose contract with USC has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Profession Code, or fraud or other criminal activity.

(5) Nothing in this policy shall preclude USC from providing continuity of care beyond the requirements of the policy.

(6) Completion of treatment shall be arranged for and monitored as follows: Transfer of medical treatment to the USC MPN providers will be done on a case by case basis. The cases will be transferred based on complexity of care and the ability of providers in the network to absorb the increased patient load. It is the intent of the MPN to transfer as many cases as medically feasible in order to optimize medical care.

(7) Ancillary services will be provided through the vendor partners and networks under contract to the USC MPN. Referrals for services into these networks will be made by providers in the MPN.

Transfer of Ongoing Care into the MPN

“Transfer of Care” refers to situations where USC employees are treating with physicians prior to the creation of our MPN, and those physicians are not members of the MPN.  Under state law we have the right to transfer such employees, under certain conditions, into our MPN for continued medical care.   It is USC’s intention to transfer all employees currently treating with non-MPN physicians into our MPN except for in the following situations:

(1)An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a duration of not more than 30-days. Completion of treatment shall be provided for the duration of the acute condition.

(2) A serious chronic condition is a medical condition due to a disease, illness, catastrophic injury, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over a period of 90-days and requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be authorized for a period of time necessary, up to one year: (A) to complete a course of treatment approved by the employer or insurer; and (B) to arrange for transfer to another provider within the MPN, as determined by the insurer or employer. The one year period for completion of treatment starts from the date of determination that the employee has a serious chronic condition.

(3)A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of treatment shall be provided for the duration of a terminal illness.

(4) Performance of a surgery is a procedure that is authorized by USC as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the MPN coverage effective date.   

(5) Nothing in this policy shall preclude USC from agreeing to provide medical care with providers outside of the MPN.

(6) Following USC’s determination of the injured employee’s medical condition, USC will notify the employee of the determination regarding the completion of treatment. The notification will be sent to the employee’s home address and a copy of the letter will be sent to the employee’s primary treating physician. The notification will be written in a language understandable to the employee.

(7) If the injured employee disputes the medical determination made by USC,  the  employee may request a report from his/her primary treating physician that addresses whether or not the covered employee falls within any of the conditions set forth above.

(8) If USC or the injured employee objects to the medical determination by the treating physician, the dispute regarding the medical determination made by the treating physician concerning the transfer of care shall be resolved pursuant to Labor Code section 4062.

(9) If the treating physician agrees with USC’s determination that the injured employee’s medical condition does not meet the conditions set forth above, the transfer of care shall go forward during the dispute resolution process.

(10) If the treating physician does not agree with USC’s determination that the injured employee’s medical condition does not meet the conditions set forth above, the transfer of care shall not go forward until the dispute is resolved.