The filing of Preferred Provider Networks began shortly after the passage of the Workers’ Compensation Reform Act of 1992 in accordance with 28-33-8. This section states “If the insurer or self-insured employer has filed 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.” Bi-annual renewal of the Preferred Provider Networks by the Medical Advisory Board is required.
Injured workers in the State of Rhode Island retain their right to first physician. The Preferred Provider Network (PPN) is utilized when the injured worker wishes to change from original treating physician to another physician.
Requirements in the filing of a PPN include:
1. The PPN 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-insurers who are represented by a single third-party administrator to submit a single network for the group.
2. Presentation of an original and 14 copies of the PPN to the Medical Advisory Board (Board).
3. In order to ensure that each health care provider is willing to accept workers’ compensation patients, a
signed authorization from each physician on the PPN must be filed by the insurer or self-insured employer at the time of the PPN filing. The form of authorization has been prepared by the offices of the Board and will be made available to the company filing the PPN or its representative.
4. Upon approval of the PPN, the Network is kept on file at the Medical Advisory Board offices. The company is then advised, through its representative, that it is recommended the PPN be posted at the place of business(es) and that each employee of the business(es) be provided a copy of the PPN. In extreme circumstances, individual notification can be waived pending prior approval by the Medical Advisory Board Administrator.
5. Should the PPN not be approved, the Board’s staff will notify the company through its representatives of whatever changes need to be made to effectuate approval of the PPN. This notification will be done either at the meeting, by telephone, or in writing.
6. 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 with the assurance that the physicians/health care providers will be readily available to provide the service required.
7. There should be geographic diversity in the PPN of health care providers to allow for patient convenience. This diversity is of greater importance for physicians in categories that will in general provide the most care; i.e., orthopedics, general surgery, neurosurgery, physiatry, chiropractic, family practice, podiatry, etc. Other specialties certainly will be required in some cases.
8. There may be a multiple choice of health care providers who will provide other special services to the injured workers; i.e., ophthalmologists, neurologists, urologists, psychologists, psychiatrists, and so forth.
9. The size of the PPN should depend on the number of employees served by that specific PPN and the geographical distribution of the units of the facility utilizing an individual PPN.
10. The PPN itself should consist of the following:
The names and business addresses and telephone numbers of each health care provider who has signed an authorization to be included in the PPN. The health care providers should be listed by category of specialty.
If the health care provider is employed by or under contract with the insurer, self-insurer, 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.
The geographical areas proposed to be covered by the arrangement as it related to the facility operated by the employer.
A demographic page showing what percentage of the employees live in what communities in the state: i.e., 50% in Providence, 25% in Kent County, etc.
Injury history may be presented to demonstrate the types and quantity of injuries during the past two years. This information will aid the Medical Advisory Board in determining sufficient choice.
11. In the case where a covered employee requires the services of a specialty not represented with the PPN, the employee remains free to choose the health care provider of his or her choice.
12. Complaints and disputes as they relate to the Preferred Provider Networks shall be submitted to the Chief Judge of the Workers’ Compensation Court who may settle the dispute or may refer it to an arbitration group which may include some members of the Medical Advisory Board appointed by the Chief Judge.
13. Should any changes occur within the PPN, the representative of the company for which the PPN stands is required to file changes within thirty (30) days to the Medical Advisory Board of the Workers’ Compensation Court.
14. Please submit PPNs to:
Office of the Secretary
Workers’ Compensation Court
Medical Advisory Board
One Dorrance Plaza
Providence, Rhode Island 02903