In January of 2010, Riverside Transportation Agency (RTA) awarded Intercare and InterMed a contract to provide claims administration, managed care and medical provider network (MPN) services.
As part of the MPN services, InterMed identified the geographic service area necessary to provide medical care to injured workers. With the assistance of our managed care team and claims team, RTA carefully selected the providers to be included in their MPN.
Selections were based on employers' preferences and evaluated according to providers' outcomes and return-to-work philosophies. Based on these criteria, some providers — even though they were part of a clinic or larger group — were not included in the RTA MPN. InterMed individually contracted with the selected providers regardless of their location or clinic involvement. Once the network was determined, it was submitted to the State and approved in mid 2010.
Following the approval of the MPN in 2010, a coach driver for RTA was involved in a motor vehicle accident. The claimant, who had injured his head, left hand, right shoulder and left ankle, began treatment outside of the RTA MPN network. The treating provider alleged that he was part of the network, because several other doctors in the clinic were MPN providers. The Intercare adjuster, Judith Watson, objected to the treatment because it was outside of the MPN.
The case was litigated by the provider and set for hearing at the Workers' Compensation Appeals Board (WCAB). The defense of the MPN started on June 21, 2011. The judge heard testimony regarding the MPN and the contracting process undertaken for the development of the MPN from an RTA representative, Judith, and the MPN manager for InterMed.
On December 26, 2012, the judge found in favor of RTA and determined that the provider was not part of the MPN.
The savings in this case were substantial; the non MPN doctor had rated the injured worker at 100 percent permanent disability, and the anticipated expense would have been in the hundreds of thousands.
The non-MPN doctor had also accumulated a considerable amount of money from medical treatment performed by himself and four other non-MPN specialties. RTA was not responsible for any of these costs.