Rule 6.9 - Preferred Provider Networks (PPN).(A)Purpose. -- G.L. 1956 § 28-33-8 provides: "[I]f the insurer or self-insured employer has a preferred provider network approved and kept on record by the medical advisory board, any change by the employee from the initial health care provider of record shall only be to a health care provider listed in the approved preferred provider network." Injured workers in the State of Rhode Island retain their right to choose their first health care provider. The PPN is utilized when the injured worker wishes to change from the original treating health care provider to another health care provider. (B)Requirements for Approval.(1) The PPN must offer a sufficiently wide selection of qualified physicians and other appropriate health care providers in various fields to allow adequate choice to the injured worker and to assure that the health care providers will be readily available to provide the service required. (2) There must be geographic diversity of health care providers in the PPN to allow for patient convenience. This diversity is of greater importance for health care providers in categories that will, in general, provide the most care; i.e., orthopedics, general surgery, neurosurgery, physiatry, chiropractic, family practice, podiatry, etc. There must be a multiple choice of health care providers who will provide other special services to the injured workers, e.g., opthalmologists, neurologists, urologists, psychologists, psychiatrists.(3) The size of the PPN must reflect the number of employees served by that specific PPN and the geographic distribution of the units of the facility utilizing an individual PPN.(C)Application Contents. -- The applicant requesting approval of a PPN must provide the following: (1) a cover letter requesting approval of the proposed PPN; (2) the applicant's signed acknowledgement that it will comply with the requirements of G.L. 1956 § 28-33-8; (3) the names, business addresses and telephone numbers of each health care provider who has signed an authorization to be included in the proposed PPN. The health care providers should be listed by category of specialty; (4) if the health care provider is employed by or under contract with the insurer, selfinsurer or group self-insurer, the organization shall set forth the nature of the contract or agreement and the frequency and regularity with which the organization calls upon the expertise of said health care provider, if applicable; (5) the geographic areas proposed to be covered by the network as it relates to the facility operated by the employer; (6) a demographic page showing what percentage of the employees live in what communities in the state, e.g., 50% in Providence, 25% in Kent County;(7) an injury history may be presented to demonstrate the types and quantity of injuries incurred by employees during the preceding two (2) years. This information will aid the Medical Advisory Board in determining if there is sufficient choice of health care providers; (8) copies of all contracts related to the creation or management of the proposed PPN with, by, and/or between the applicant and any third-party administrator, preferred provider organization, health care provider or other entity involved in the administration of the proposed PPN. Proprietary information contained in said contracts may be redacted;(9) a signed authorization from each health care provider on the proposed PPN must be filed by the insurer or self-insured employer at the time of the filing of the application. The most current form is located on the Rhode Island Judiciary's website at www.courts.ri.gov under the heading of Forms, Workers' Compensation Court. Contents of said applications are proprietary in nature and not available for public viewing.(D)Procedures for Approval. (1) The PPN application must be submitted by the insurer or self-insured employer who wishes to utilize a PPN in providing care for injured employees. It is not acceptable for a group of self-insured employers who are represented by a single third-party administrator to submit a single network for the group. (2) Incomplete applications will be returned to the applicant with an explanation as to why the application is incomplete. Should the insurer/self-insured employer not respond to this notification further as directed, the Administrator may, at her/his discretion, bring the application to the Medical Advisory Board for a final vote of approval or denial. (3) Upon receipt of a complete application as outlined in W.C.C. - R.P. 6.9, the application will be placed on the agenda of the next meeting of the Medical Advisory Board for a vote to either approve or deny the application. (E)Consideration and Vote by the Medical Advisory Board. (1) Representatives of the proposed PPN may appear before the Medical Advisory Board to answer any questions and present any additional information. (2) After reviewing and discussing the proposed PPN, the Medical Advisory Board may make recommendations and table its vote, or vote to approve or deny the application. (3) A Medical Advisory Board member shall recuse from voting or discussion if that member, a business associate, employer, or family member appears on the proposed network. However, when a majority of the Medical Advisory Board members must recuse themselves from consideration of a PPN, then, pursuant to the "Rule of Necessity" exception, the number of affected members necessary to establish a majority/quorum may participate in the vote.(F)Approval of the PPN by the Medical Advisory Board. (1) Upon approval, the PPN will be kept on file at the Medical Advisory Board Office. (2) The insurer/self-insured employer shall post the PPN at each place of business and shall provide each employee with a copy of the PPN. In extreme circumstances, individual notification may be waived pending prior approval by the administrator of the Medical Advisory Board. (3) Should any changes occur within the PPN after approval by the Medical Advisory Board, the representative of the insurer/self-insured employer shall file a notice of such change within thirty (30) days with the Medical Advisory Board. Substantial changes may require further approval by the Medical Advisory Board. (G)Non-approval of the PPN by the Medical Advisory Board. (1) If the Medical Advisory Board does not approve the PPN, the insurer/self-insured employer will be notified as to the additional information or changes that may be needed to effectuate approval of the PPN. (2) Submission of this additional information or execution of changes shall be accomplished as further directed by the administrator of the Medical Advisory Board.(3) Failure to submit this additional information or execution of changes as further directed may result in the administrator moving for a final vote of approval or denial of the application in its current form. (H)Complaints, Disputes or Appeals Regarding Preferred Provider Networks. (1) The chief judge of the Workers' Compensation Court may review and/or settle any complaints or disputes regarding any PPN.(2) If the chief judge is unable to resolve any complaint or dispute, the aggrieved party may file an appeal to the Workers' Compensation Court pursuant to W.C.C. - R.P. 2.30.R.I. Work. Comp. Ct. R. 6.9
Reporter's Notes. - In reference to W.C.C. - R.P. 6.9(C)(8), contracts submitted as part of an application will be reviewed to ensure compliance with G.L. 1956 § 28-33-8 which states: "any contract proffered or maintained which restricts or limits the health care provider's ability to make referrals pursuant to the provisions of this section, restricts the injured employee's first choice of health care provider, substitutes or overrules the treatment protocols maintained by the medical advisory board or attempts to evade or limit the jurisdiction of the workers' compensation court shall be void as against public policy."
The Medical Advisory Board has existed and operated under these rules since its inception in 1992. These rules have been modified over the years to ensure the provision of high quality medical care to injured workers, while preventing unnecessary delay in return to work or excessive costs to the system. The Medical Advisory Board was created pursuant to G.L. 1956 §23-30-22 as a branch of the Workers' Compensation Court. The Rules of Procedure of the Medical Advisory Board have been incorporated into the Workers' Compensation Court Rules of Practice. This incorporation will assist all parties appearing before the Medical Advisory Board. These rules clearly detail the hearing process and specifically note compliance with W.C.C. - R.P. 2.30 in regard to appeals made to the Workers' Compensation Court.
The terms health care providers, medical service providers, and health service providers are used interchangeably in these rules and are considered to be any persons who have provided health care services to injured workers.